Added by Anne Beckett on 24.08.2020 | Reviewed by

What is bariatric revision surgery?

The revision of bariatric surgery takes place after the initial weight loss procedure in order to correct, improve, reverse or convert the original procedure.

The annual number of NHS primary obesity procedures peaked in England in 2011/2012 at 8,794 performed operations although in 2017/18 (the latest figures available) this had dropped back slightly to 6,627. In addition, it is estimated that up to 5,000 primary procedures are performed on English patients in the private sector both in the UK and overseas. Over three-quarters of these patients are women in the age group 35-64 years. Realistically, therefore, most of these patients have between 20-50 years longer to live with their bariatric procedure. It is no wonder that gastric revision procedure is sometimes needed. The UK National Bariatric Surgeon Registry estimates that in 2015/16, 11% of total weight loss surgeries performed were bariatric revision surgery.

In 2011, according to the American Society for Metabolic and Bariatric Surgery (ASMBS), the estimated number of bariatric revision procedures in the USA was around 9,480. In 2018 (latest data available) 252,000 bariatric procedures were performed of which about 15% (around 37,800) were revision bariatric surgery.

Size plus women

Gastric revision surgery takes place after the initial weight loss procedure, the purpose of it is to correct, improve, reverse or convert the original procedure. Usually, take place when the first surgery didn’t help

So, year-on-year the gastric revision procedure is on the increase.

Gastric bands become faulty, complications occur and patients do not lose the anticipated amount of weight. The incidence of bariatric surgery revision is expected to continue to rise steadily over the next few years.

Infrequently the revision surgery is pre-planned when two procedures are performed independently of each other and with a planned time gap. This happens, in certain circumstances, e.g. when a biliopancreatic diversion is performed followed by a duodenal switch some months later.

Generally, the definition of revision surgery is a procedure which takes place more than 90 days after the first surgery.

Reasons for revision weight loss surgery

The reasons for bariatric revision surgery are almost as numerous as the number of people requiring it, from gastric bypass revision due to ulcer to gastric band slippage.

However, most reasons for a second bariatric procedure fall into five categories:

  1. Complications due to the first procedure
  2. Either failure to lose weight post-surgery or significant weight gain after initial success
  3. Accompanying conditions e.g. diabetes, heart issues etc do not improve or come back
  4. A combination of any of the above factors
  5. Very rarely, but occasionally, where there is excessive weight loss, malnutrition or intractable diarrhoea

Research on a small number of patients in 2014 put the rates of revision surgery as:

  • For patients originally given gastric band surgery: 20%-60%
  • For patients originally given gastric bypass surgery: 9%-17%
  • For patients originally given gastric sleeve surgery: 9%-11%

Why do revision surgeries happen?

Bariatric surgery revision surgeons estimate that about 50% of revision surgeries take place because the patient has, so to speak, ‘fallen off the wagon’. After the initial euphoria of a big weight loss, the patient becomes more complacent. Unhealthy food creeps into the diet, exercise becomes less and less and gradually the weight creeps back on, the stomach is stretched and the original bariatric surgery is ‘no longer working’! Having said that, that still leaves about 50% of patients who have technical/medical problems outside their control.

Gastric revision surgery-options

Gastric Bypass Revision

Where gastric bypass revision surgery is necessary because the original procedure is not producing the required weight loss results, the first thing the surgeon will request is that the patient keeps a food diary. This will establish the true reason for the weight gain – overeating or a medical issue. An x-ray will also be taken to check how things are looking in the stomach.

In cases where the stomach has stretched, there are a few gastric bypass revision surgery options:

  • A band can be placed around the stomach pouch to reduce its size (a gastric band)
  • The stomach can be stapled – as in the gastric sleeve procedure – to reduce its size. This means removing some of the stomach and reducing the size of the passageway to the intestines.
  • Even more of the intestines can be bypassed, so fewer calories can be absorbed
  • The connection between the stomach and intestines can be tightened endoscopically – without having to perform another surgery. However, this is a fairly new procedure and its long-term success rate is difficult to assess,

Other problems vary, but generally physical issues like problems with the anastomoses (connections) between the stomach and intestines can also be often resolved with another round of surgery.

More complicated issues, however, may require different gastric bypass surgery revision. A mini-gastric bypass may sometimes be reversed, but this is not an option available for the roux-en-y gastric bypass. If there are major problems with a gastric band bypass then it may have to be converted to a duodenal switch or gastric sleeve.

Research in a small group of just 12 patients in 2016, who were suffering from ulceration, narrowing of the oesophagus, dumping, gastro-gastric fistula – when the stomach pouch re-attaches to the original stomach – and hypoglycaemia (low blood sugar), showed that complications of 11 of the patients were resolved after a conversion from a roux-en-y gastric bypass to a gastric sleeve. The gastric bypass revision success rate was therefore very high.

Gastric Sleeve Revision Surgery

Gastric sleeve bariatric surgery is now the most popular weight loss surgery. It is currently considered as the safest and usually most effective, however, it too can have its problems.

Sometimes the stomach pouch – ‘sleeve’ – is just too big to start with or over time it stretches. Long term medical risks of a gastric sleeve procedure include gastrointestinal obstruction, hernias, gastroesophageal reflux, hypoglycaemia, malnutrition and severe vomiting.

When the issue is purely a problem with the size of the stomach pouch i.e. it was originally too big or it has stretched over time, corrective surgery can be done to reduce the size of the stomach pouch further. However, where the problems are more severe, gastric sleeve revision surgery in the form of a conversion to another type of weight-loss procedure may be necessary. In fact, a gastric sleeve is the first step in the Biliopancreatic Diversion With a Duodenal Switch procedure, so this procedure may be the most obvious way to convert the gastric sleeve. Sometimes a Roux-en-y gastric bypass is also used. Both of these have been shown to be good alternatives for the patient to increase their weight loss and reduce or eliminate their chronic conditions.

Gastric Band Revision

Up until a few years ago, gastric band or lap band surgery was the most popular weight loss surgery. However, its popularity has waned over the last few years mainly due to the long term issues which are starting to appear. Currently, about one-third of gastric band operations will need revision and this number is expected to rise. With the gastric band procedure, there is the added problem of mechanical failure occurring with the band or port. Additionally, the bands can slip, erode or simply fail, while the port can move so that it is no longer accessible. In addition, they can both cause infection in the body or sometimes leak. Sometimes the revision means replacing or adjusting the band or port, at other times it may mean completely reversing the procedure, which of course may lead to weight gain. Often gastric band revision, therefore, can mean conversion to another bariatric procedure. Revision from lap band to gastric bypass is the most frequently performed conversion surgery. This is the preferred procedure because it can work around any scar tissue leftover from the gastric band. In certain circumstances, gastric band revision to sleeve is also possible.

 

 

How to choose the best option?

Doctor in the kit

The patient is always informed about options after consultation with the surgeon. All circumstances must be taken into consideration and the doctor will choose the best revision surgery for the patient

The question often asked is: when it comes to revision, which gastric surgery is best for me? That’s a tough one to answer without knowing all the circumstances. If the problem is that weight loss has stopped, or even weight is being gained, then the bariatric surgeon will need to know what the reason is. If it is being caused by overeating or eating calorie-laden meals then no amount of revision surgery is really going to help with that. However, if the reason is something has ‘gone wrong’ with the original surgery, then the surgeon may suggest a correction, or indeed a conversion to another procedure. Obviously, where there is a pressing medical issue associated with the problem or a worsening or threatening medical complication, decisions will need to be made fast, and the surgeon will be guided by how best to ensure the patient’s medical condition is improved. So, in answer to the question: which weight loss surgery is best for me as a revision, the answer has to be, please discuss it with the surgeon, he/she is the person best placed to provide the revision options in the specific circumstances.

 

Recovery time for gastric revision surgery

Actually not all revisions need traditional surgery – occasionally some can be done endoscopically via a tube placed down the throat.

In the hospital

Revision surgery is always more difficult than the initial surgery, because of this recovery time tends to be longer than for the first time. Usually, patients have to spend a day or two longer in hospital than for the original surgery

Due to thickening and scarring, however, revision procedures are always more difficult than the initial surgery, regardless of how it is done. For this reason recovery time for gastric bypass revision surgery or any of the other procedures mentioned above, tends to be longer than for the first procedure. Sometimes it is not possible to do the revision surgery laparoscopically and the stomach will need to be assessed in the traditional way by cutting it open. This may extend the recovery time as the wound may take longer to heal. Generally, patients can expect to spend a day or two longer in hospital than for the original surgery, but the ‘home’ recovery time will be about the same. For example, the recovery time for gastric bypass revision surgery is about two weeks.

Similar precautions should be taken as those for the original surgery or indeed any surgical operation. These include caring for the wound, moving around as soon as possible to prevent blood clotting but at the same time getting plenty of rest to ensure that the body can recover from the trauma. Additionally, of course, patients will only be allowed a liquid diet for the first few days. A gastric bypass revision diet, for example, is exactly the same as that for the original gastric bypass operation and likewise with any other procedure.

Always be guided by the consultant, but the usual diet pattern after any gastric surgery is:

  • The first month after the operation clear liquids only for the first few days, progressing to thicker liquids (e.g. milk drinks, yoghurts etc.)
  • The second month after the operation soft food and puréed meats and vegetables progressing to semi-solid foods
  • The third month after the operation and ongoing a ‘normal’ diet, but with small portions and healthy choices of food

Weight Loss after revision surgery

Scale and meter

Usually, weight loss revision surgery is successful, but weight loss success depends on the patient following a good, healthy diet plan

Usually, weight loss revision surgery is successful, both in terms of correcting a physical problem with the original procedure and in terms of increasing weight loss in the patients. If previous lack of weight loss has occurred because something has gone wrong with the initial procedure e.g. stomach pouch is enlarged or gastric band has slipped, then a correction or conversion to another type of bariatric procedure will solve the physical problem. Often, this will also give the patient a boost of motivation to restart their eating plan anew. In exactly the same way as the initial surgery, however, ultimately weight loss success depends on the patient following a good, healthy diet plan.

There is some research available on the safety issues surrounding revision bariatric surgery but little data on weight loss specifics. It is generally agreed that the weight loss after can be quite substantial although not as dramatic as the primary surgery.

Risks and complications of revision weight loss surgery

Due to scarring and thickening of the tissue, surgeons agree that revision weight loss surgery is more complicated than the initial surgery and there is a slight increase in the risks and complications. Research in 2017 (Courtney Fulton et al) comparing complications between patients who had initial gastric bypass bariatric surgery laparoscopically (397 patients) and patients who had revision gastric bypass surgery in an ‘open’ operation (66 patients) showed very different incidences of complications:

Complications


Primary Gastric Band (laparoscopically) %


Revision Gastric Band
(open surgery) %


Leak0.9
4.5
Bleed6.00
Infection at wound/abcess15/336.4
Stricture7.44.5
Ulcer8.79.1
Fistula0.49.1
Bowel obstruction0.74.5
Hernia3.712.1

From this, it can be seen that, in most cases, the incidence of complications occurred more frequently with the revision surgery, partially because they were all performed as an open operation. Only the frequency of bleeding and stricture (constriction of a tube e.g. oesophagus) was lower than in the primary surgery.

Although the pattern may be slightly different this general trend of increased risks also applies to gastric bypass revision complications.

However, all of this must be put into the context of why the revision surgery is taking place. Sometimes it is essential when major complications have arisen in connection with the initial surgery. Sometimes it is needed, where an increase in weight or lack of weight loss means that a chronic condition like diabetes or hypertension has returned. Similarly to all surgery, the patient and consultant must weigh up the limited risks of having the surgery against the risks of not having the surgery.

Cost of bariatric revision surgery

Usually the cost of bariatric revision surgery is given individually and depends on the chosen option

When talking about the cost of bariatric revision surgery there is a whole host of different variables to take into consideration. Is it just a corrective procedure? Is it a reversal procedure or a conversion procedure? Are there complications with the initial procedure? etc. It is true to say that a revision procedure will always take a little longer and be more complicated than an original procedure. So, for example, the gastric bypass revision cost will be more expensive than the gastric bypass cost as an initial procedure.

Here are a few examples of prices patients might expect to pay in the UK:

  • Removal of the gastric band: £3,500
  • Correction to a gastric bypass £5,000
  • Conversion of gastric band to the gastric sleeve/bypass £11,000

Revision surgery on the NHS

For the purposes of allocating funds for bariatric revision surgery, the NHS divides patients into 3 groups.

  • Group 1: Patients who have a history and symptoms that suggest acute or worsening medical and/or surgical complications – relating to their original operation.

For these patients, immediate treatment will be offered as an emergency. This will normally take the form of corrective surgery or complete reversal. Sometimes revision to another bariatric procedure may be possible. Under its ‘duty of care’ policy the NHS would also offer this service (in the same circumstances) to those eligible for NHS services but who had their original bariatric surgery performed privately either in the UK or abroad.

  • Group 2: Patients who have failed to lose their target weight or those who have started to regain weight, including where the gastric pouch has become stretched.

In normal circumstances, neither NHS or private patients will be funded for additional surgery

  • Group 3: Patients who have severe and potentially life-threatening conditions which have never disappeared or which have re-appeared such as diabetes and cardiovascular risks. NHS’s patients only may be considered for revision surgery but the consultant has to apply for special funding.

Thus, it is probably fair to say that, gastric band revision surgery NHS is not very easy to come by.

It is worth noting, however, that any complications arising within 90 days after the initial bariatric surgery are regarded by the NHS as being part of that initial surgery and not revision surgery.

Is revision surgery covered by insurance?

The majority of private health insurance providers in the UK do not offer any type of bariatric surgery in their insurance packages. The few exceptions which exist fund a certain percentage of the costs with the patient paying the remainder. This does not, however, normally apply to revision surgery although it is always worth a phone call to the insurance company to ask them the question: is bariatric revision surgery covered by insurance.

In other countries, it may also be difficult to persuade the insurance company to foot the bill for a bariatric revision. Certainly, where the initial procedure has ‘failed’ because the patient has not followed a good healthy eating plan but there is nothing physically wrong with the original procedure, it will be very difficult to persuade an insurance company to fund the revision surgery.

Revision surgery abroad

With the difficulties in securing NHS bariatric revision surgery and considering the cost of private revision bariatric surgery in the UK and other western European countries, it is no surprise that patients look to other countries where savings of up to 50% can be found.

flying airplane

Weight loss revision surgery abroad grows in popularity. There are many great options available with a really good cost

With the explosion in budget flights within Europe, obtaining medical services abroad is no longer a big problem. Similarly to in the UK, it is difficult to put a definitive cost on bariatric revision surgery abroad. The surgeon will need to know exactly what the problem is and assess the patient’s eating patterns, before deciding on the exact revision surgery required. The surgeon will normally require all the necessary information like which procedure was the initial bariatric surgery, what the current problem is, what the patient’s current eating patterns are and possibly x-rays of the stomach. Only then will he/she be able to advise, what in their opinion, is the best solution and what the exact cost will be. When considering any surgery overseas, it is always important to factor in prices of flights both for the initial surgery and any return appointments if necessary and accommodation. Sometimes it is possible to purchase an aftercare package in the UK after bariatric surgery abroad.

Revision surgery in Poland

Poland is considerably cheaper than in the UK. However, that does not mean that quality and standards are in any way compromised. Clinics/hospitals are fitted out with state-of-the-art equipment and staff speak very good English. Prices are only cheaper due to the lower cost of living, not because of inferior medical standards. Weight loss surgery Poland is very popular. All doctors and medical staff are trained to the highest level and customer service is very good. Additionally, there are numerous flights to many airports in Poland, often operated by budget carriers like WizzAir and Easyjet. Depending on the time of year and advance booking period it is possible to get airline tickets from the UK to Poland for around £20 one way – cheaper than a rail ticket to London from many UK locations. The flight UK to Poland is around 2½ hours, so not too long a journey. It is not unusual for a revision surgery procedure in Poland to cost about half the price of private treatment in the UK and many other Western Europe countries.

Revision surgery in Turkey

Bariatric surgery in Turkey has become ever more popular over the last few years, and revision surgery is no exception to this rule. Clinics and hospitals, particularly those that cater to private overseas clients, are of the highest standard. Often modern high-tech equipment is available and medical staff speak English. Flight times from the UK to Turkey are longer than to other parts of Europe but, an added bonus is that post-surgery the patient can relax in the warm sunshine. Due to its popularity as a holiday destination, there are frequent flights to major airports in Turkey. Similar to Poland, weight loss surgery in Turkey is much cheaper than in the UK or Western Europe and savings of up to 50% can often be achieved.

Revision Surgery Summary

Bariatric revision surgery usually takes place due to a fault which has developed in the original surgery, complications that have risen, or because the patient is no longer losing weight. The revision surgery can correct any problems or complications with the original procedure, reverse the original procedure (where possible) or convert the original procedure to another type of bariatric surgery. Weight loss results after revision surgery are often good, but not as dramatic as for the original procedure. Revision surgery carries a higher risk of complications than for the original surgery, however these risks may have to be weighed up against the possible risks of not having the revision surgery. Generally it is quite difficult to obtain revision surgery through the NHS unless in an emergency, and it is unlikely that private medical insurance will foot the bill. The revision surgery can be quite expensive, however big savings can be made by having the procedure performed abroad.

Sources:

The United Kingdom National Bariatric Surgery Registry: https://www.bomss.org.uk/wp-content/uploads/2017/03/Bariatric-Surgery-Clinical-Outcomes-Publication-for-2015-16.pdf

NHS Statistics on Obesity, Physical Activity & Diet: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/613532/obes-phys-acti-diet-eng-2017-rep.pdfConversion from gastric bypass to sleeve gastrectomy for complications of gastric bypass:

https://www.sciencedirect.com/science/article/abs/pii/S1550728915002865

ASMBS: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbersLong-Term Effectiveness of Laparoscopic Conversion of Sleeve Gastrectomy to a Biliopancreatic Diversion With a Duodenal Switch or a Roux-en-Y Gastric Bypass Due to Weight Loss Failure: https://pubmed.ncbi.nlm.nih.gov/29374818/

A Comparison of Revisional and Primary Bariatric Surgery : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5453764/

https://thegastricguru.com/

https://columbiasurgery.org/news/2017/08/14/when-revise-weight-loss-surgery

https://www.multicare.org/happy-back/blog/revision-surgery-what-is-it-why-need-after-bariatric/

https://www.summitmedicalgroup.com/news/living-well/Revision-Weight-Loss_Surgery/

Anne Beckett

In the UK Anne was a professionally qualified trainer with many years of experience in the training industry. She mainly worked in the travel, tourism and leisure industries (including Thomas Cook and British Airways) as well as in other sectors.

Since moving to Poland  twelve years ago, Anne has become involved in other business sectors – teaching English as a foreign language and translating documents from Polish into English. She specialises particularly,  in  medical translations and  works closely with dentists, cardiologists and neurologists in translating and preparing articles for publication. She has also trained as a practitioner in the field of neuro-linguistic programming and is a qualified hypnotherapist.

Any spare time is spent renovating the house in Poland which Anne bought some years ago.

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