REVISION BARIATRIC SURGERY IN MEXICO

WHEN IS REVISIONAL WEIGHT LOSS SURGERY NEEDED?

• Insufficient weight loss after the initial procedure or weight regain.
• A second bariatric surgery may be planned intentionally for patients with very high BMI who do not qualify for a bypass initially due to a high risk of complications. They choose to start their weight loss journey with a less invasive procedure such as gastric sleeve and once certain weight loss has been achieved, they move further to RNY bypass as their second step to achieve best results.
• Short term or long term complications after the original procedure. For example, a revision from gastric sleeve to RNY gastric bypass is recommended for patients who developed severe GERD (acid reflux) after the sleeve surgery. Revision from lap band to gastric sleeve or bypass are often needed due to band slippage or side-effects such as constant nausea and vomiting, or rapid weight regain after removing lap band or gastric balloon. 
• Excessive weight loss that requires a reversal procedure such as bypass reversal.

IS WEIGHT LOSS FAST AFTER REVISIONAL WEIGHT LOSS SURGERY?

Any time we lose weight repeatedly, weight loss becomes slower and slower with each new attempt. This happens regardless if we lose weight with the help of surgery or by dieting only. Why? Our body turns on a survival mechanism. “Remembering” previous weight loss experiences, our body tries to prepare itself for the next “starvation”, and in order to survive slows down metabolism utilizing its already stored energy (fat tissue) economically, thus “resisting” weight loss. And as soon as the patient stops following the healthy lifestyle (often due to frustration from slow process and lack of patience and commitment) and returns to his former eating habits, his organism will quickly regain all the weight lost and try to store extra energy to be better prepared next time. This is the reason why the so-called yo-yo dieting never works and why we always not only regain the weight we have lost but add some extra to it.

Weight loss after revision surgery is steady, although slow, and extra physical activity helps a lot, as you have to “convince” your body to utilize energy sources – the fat tissue, and it will take time and extra effort. But trust the process and be determined to succeed!

 REVISION FROM LAP BAND SURGERY, WHAT TO CONSIDER?

Any time a lap band is still in place, it is important to have a preoperative endoscopy done to rule out possible complications that lap bands sometimes cause, such as erosion, band slippage, port infection, etc. Upper GI series may also be required, especially if the patient had band slippage in the past. It is always recommended to remove fluid from the lap band before surgery (if possible).

If the patient is not able to have an endoscopy done prior to traveling to Mexico (for reasons such as no insurance coverage, high deductible costs, etc), it will be arranged with our endoscopist on the day of surgery in the morning under light sedation, after which the patient will wake up and discuss the endoscopy results with the surgeon prior to proceeding with the revision surgery.

There is a small chance that in case an erosion is diagnosed, the surgeon will not be able to proceed with the revision to gastric sleeve or bypass, but will have to remove the lap band first and allow sufficient time for the stomach to heal and erosion to resolve. Only then, after 6 months or so, a revision will be possible.

Any time the lap band has already been removed and the patient is looking for revision to promote further weight loss, a regular endoscopy that is performed during surgery will be sufficient, since there is no risk of erosion anymore. Such surgery is still considered revisional due to the scar tissue that formed during lap band placement and removal, which complicates the next procedure and requires longer OR time, thus increasing surgery costs.

 IS RE-SLEEVING AN OPTION (GASTRIC SLEEVE TO GASTRIC SLEEVE REVISION)?

Performing another gastric sleeve over an already existing sleeve is not recommended and often not possible. First of all, because normally there is not enough stomach tissue to work with and to be able to perform a double staple line as well as an additional suturing line over it. There would be a risk of making the stomach too narrow and potentially causing such complications as a stricture or stenosis where food would not be passing through the stomach properly.

Secondly, if the patient did not succeed with the initial gastric sleeve, as the next step a more “harsh” procedure is recommended, such as Mini or RNY bypass. It provides not only a restrictive effect (that you had originally but it wasn’t sufficient to achieve ideal results) but also a malabsorptive effect, that will not allow your body to absorb all the nutrients from the limited amount of food you eat. Considering that any revision surgery provides slower weight loss, a more invasive procedure will increase your chances of achieving your goal.

Finally, hypothetically, re-sleeving is possible if a test is performed called stomach volumetry that measures the size of the stomach. If the size is 500 ml or larger, then there is enough stomach tissue to work with and re-sleeving is possible. But our medical team does not recommend it for the reasons explained above.

But what if you wish to preserve an already existing gastric sleeve and add a malabsorptive effect to it? In that case we recommend a revision to the SADI-S procedure (also known as Single Anastomosis Duodenal-Ileal Bypass with Sleeve).

 BYPASS REVISION (RNY TO MORE DISTAL RNY), WHAT TO CONSIDER?

To learn whether you are a good candidate for a revision of an already existing RNY bypass, an endoscopy and an upper GI are required.

With a bypass revision the surgeon tries to complete all of the following steps in order to make such a revision worth the patient’s financial expenses and risks, and to increase the feeling of restriction.

1. Making anastomosis tighter (also called stoma – the connection between the stomach pouch and the small intestine), so you can feel a stronger restriction.
2. If your stomach pouch is stretched or was made too wide originally, the doctor might be able to make it smaller.
3. Bypassing the small intestine even further, also called distal bypass. When a bypass is performed originally, Dr Zavalza and Dr. Hernandez bypasses about 6 to 7 feet of the small intestine to provide a mal-absorptive effect. If the surgeons see that it is safe to bypass more, or that not enough was bypassed during the first surgery, they will be able to fix that and provide stronger malabsorptive effects. Of course there is a limit as to how much of the small intestine can be safely bypassed, as if bypassed too much, the patient will be suffering from diarrhea for the rest of their life.
4. Medication approach. Yet another step could be a non-surgicaltreatment with Saxenda that has proven to be quite effective. This is a very new medication on the market, and further research is still required. However, based on what we have already learned, it can be used in patients who are undergoing revisional surgery and need an additional tool either initially or later during the weight loss process. Whether this step is necessary is determined by the surgeon during the consultation pre-op or post-op, and if need be, Saxenda is prescribed as a 6-months course and is self-administered via abdominal injections under the doctor`s guidance.

Every patient who considers a revision of a bypass has to discuss this thoroughly with the surgeon during a pre-op consultation, and it is best to provide results of an endoscopy and Upper GI before coming to Mexico, so you and the doctor can evaluate better what steps among those listed above can be done and whether you will feel a major difference. This will determine whether this surgery is worth all the effort and expense.

 REVISION OF A BYPASS DONE IN THE US VS REVISION
OF A BYPASS DONE IN MEXICO?

Based on our experience, revision of RNY bypass originally performed in the US is rarely possible as the technique the surgeons use in the US is slightly different compared to the technique used by the Mexican doctors.

In the US the doctors prefer to create a shorter but wider stomach pouch. And as explained above due to the short length of such a pouch, creating new anastomosis is not possible.

Whereas in Mexico most surgeons create a stomach pouch that resembles a sleeve: it is narrow but longer, thus it leaves room for a revision in the future if necessary (in case of a complication or for any other reason).

The volume of the stomach pouch is more or less the same in both techniques.

Of course every patient always needs to be evaluated individually, but knowing this difference in approach among the surgeons, you can have a better idea of what to expect depending on where your original bypass surgery was performed.