May - Jun 2014

Surgical Revision and Gastric Bypass

By Hugh Houston, MD


In reality, the vast majority of patients do not need revision surgery. The most common complaint we see with patients who have gained weight back after gastric bypass surgery is: “my pouch has stretched out”. For some patients this is true to an extent and we’ll discuss that in a minute. However, most patients simply have reverted back to poor eating habits. When I ask them how much chicken and vegetables they can eat at one time, the response is invariably… “I don’t know”.  Well, there is their answer. They should know!

 

Keep in mind that bariatric surgeries are tools. Their main function is to help control appetite and portion sizes. We know portion sizes will increase some over time but it’s not usually due to major stretching of the pouch. However, a pouch may have been made too big in the beginning but felt small at first due to the restriction and swelling from the surgery. After that wears off, the pouch can get bigger—and so do portion sizes. This only happens to a small minority of the patients we see who may actually be good candidates for a revision. They typically had their surgery performed either many years ago or as an open bariatric procedure. Most laparoscopic gastric bypasses are made with small pouches that don’t stretch much over time.

 

Another potential cause of weight gain after gastric bypass surgery is stretching of the opening between the pouch and small bowel connection (termed anastomosis) over time. This can lead to faster emptying of the pouch which allows you to eat more or be less full with a meal. However, there is only so much that can be done surgically to maintain that small opening over time. Things have been tried like banding the opening with an adjustable gastric band. This may help some patients but it can lead to surgical complications due to the foreign device being placed around the anastomosis. But, there are still failures with this approach. Remember that it’s more of a food choice issue that ultimately puts weight back on, not a volume of food issue. There have also been attempts at tightening the opening with a scope placed through the mouth (StomaphyX or ROSE procedure). But these aren’t durable in the long run and eventually fail due to behavioral issues on the part of the patient.

 

When I’m talking to a patient who thinks he/she needs a revision, I will give an example of two sisters who had the exact surgery on the same day by me. They had the same pouch and the same anastomosis. Five years later, one sister is slender and one is struggling with her weight. The slender sister’s eating habits changed dramatically and she is now able to control her weight and deal with her body’s slow metabolism. The other sister deals with the stress in her life by snacking and making poor food choices. She feels like her pouch has stretched out, but it’s the same pouch her sister is doing great with.

 

A comprehensive program that provides lifelong access to multidisciplinary support staff such as registered dietitians, exercise physiologists and psychologists available to help with all facets of this complex disease as well as improve your ability to make the long term lifestyle changes necessary to achieve and maintain weight loss success after surgery.