May 28, 2019
Undergoing bariatric surgery can be the beginning of a longer, healthier and happier life for many patients. In some cases, however, surgery doesn’t deliver optimal results, and a second procedure is needed. Dr. Timothy Shope discusses the benefits of revisional bariatric surgery.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Timothy R. Shope, Chief of Bariatric Surgery at MedStar Washington Hospital Center. Thank you for joining us today, Dr. Shope.
Dr. Shope: Good morning. Thanks for having me.
Host: Today we’re discussing revisional bariatric surgery, or revisional weight loss surgery. Having bariatric surgery can be the beginning of a longer, healthier, and happier life for many patients. That said, some patients need a second procedure to ensure optimal results. Dr. Shope, could you start by discussing factors that might make a patient eligible for revisional weight loss surgery?
Dr. Shope: Sure. The most obvious reason someone might require revisional weight loss surgery would be if they have not achieved everything that they need to achieve from their primary procedure. We see patients that have had surgery as early as maybe a year or two ago and as far back as 10, 15, even 20 years ago. These patients have varying results after their initial procedures. Some of them do very well initially and then regain some weight. Some of them fail to achieve substantial weight loss in the first place. Another reason that patients may want to seek revisional surgery would be if they have some problem related to their initial procedure. One of the more common things that we see are things like bad reflux after one of our newer procedures - sleeve gastrectomy. We see long term complications of gastric bypass surgery including problems with the connections that are made and, actually, recreation of a connection between the pouch of the stomach and the bypassed part of the stomach. So these are some reasons why patients might need some revisional surgery.
Host: Could you describe your patient population? Are they older, younger, male, female?
Dr. Shope: Most of the patients coming in for revisional procedures are a little bit older. Not necessarily old, but 50s and 60s. Remember that some of these folks had surgery 20 years ago so they were probably in their 20s or 30s at that point in time. Some of the younger patients that we see are patients that maybe weren’t as well prepared as they thought they were for their initial procedure. They hadn’t committed to making some of the lifestyle changes that are necessary and therefore they ultimately don’t get that success that they really needed with their first procedure.
Host: Do certain procedures tend to require revision more frequently than others?
Dr. Shope: That really depends on the reason for the revision. As I had mentioned, the sleeve gastrectomy operation, in a small percentage of patients, can actually create some reflux, even if patients didn’t have reflux disease initially. Those patients - some of them can be pretty debilitated by it and really seek a treatment for the reflux disease. But that’s not common. The common things that we see are patients who had, for example, a lap band surgery 10 years ago or so that did okay but ultimately they didn’t get what they wanted and they really just want another option, another way to lose some more weight. The revisional surgeries we do for gastric bypass patients - many times those are - again, I’ll use the word complication but it’s really more of a natural progression of having that operation. The connections that were created can dilate over time. So it’s not really a severe problem that some folks might think of when they think complication but sort of a natural progression of having that operation in some patients.
Host: Just things getting more and more difficult or affecting their quality of life?
Dr. Shope: Yeah, and they’re just not able to use the tool that they had been given to its maximal effect that perhaps they had been able to 10, 15 years earlier.
Host: What procedures are available to revise a previous bariatric surgery?
Dr. Shope: Again, that’s gonna depend greatly on what was done previously. For example, if the patient had a lap band placed before, we would obviously have to remove that band but then their options include sleeve gastrectomy or conversion to a gastric bypass procedure. If patients have had a previous sleeve gastrectomy, really we can convert that operation to the gastric bypass procedure or a more complex operation that we hadn’t mentioned before called a biliopancreatic diversion duodenal switch. And, if you’ve had a gastric bypass procedure in the past, the revisions are limited. We can lengthen the bypass. We can revise either of the two connections that are created for that procedure. But again, it would depend greatly on what the specific issue is, why we might revise one versus the other. The biliopancreatic diversion duodenal switch procedure is a procedure that actually is where the sleeve gastrectomy came from. Originally, about 10, 15 years ago, surgeons were performing that procedure in two steps. Essentially they would, for patients who had complex medical problems or were at extremes of weights or body mass index, they would perform a sleeve gastrectomy, allow the patients to lose some weight with that, perhaps improve their medical problems a fair bit, and then come back for what is essentially a very lengthy small intestinal bypass procedure. They recognized that many patients weren’t needing that second procedure, and that’s how we came to have a sleeve gastrectomy as a stand alone operation. But combining the two - the sleeve gastrectomy with the lengthy small bowel bypass - creates a very nice operation called the biliopancreatic diversion duodenal switch.
Host: What risks are involved with an original bariatric surgery versus a revisional procedure?
Dr. Shope: Well, the patient’s going to be accepting essentially all the same risks that they accepted for their initial procedure. Some of these are a bit more likely to happen, for example, staple line problems with either the sleeve or the bypass. More likely to happen in a revisional procedure than they are in the primary procedure just because we’re operating on previously operated organs. Those risks aren’t dramatically increased but they are definitely slightly higher.
Host: What’s the minimum amount of time that a patient should wait before seeking a revision surgery?
Dr. Shope: Well, I think the patient needs to have tried...I don’t know exact number and some of it, again, depends on the reason that they’re seeking revision. If it’s primarily about losing more weight, then they need to have at least several years. And, in fact, insurance companies will probably halt an approval based on the length of time they have given it a good effort.
Host: What do patients have to do differently during recovery after revisional surgery to meet their health goals?
Dr. Shope: Well, they definitely need to re-approach the process of weight loss. If they haven’t achieved their weight loss goals initially, we need to understand part of why that is. Sometimes the surgery wasn’t appropriate for them. Sometimes the surgery was done correctly but wasn’t exactly what they needed. So they really need to reframe how they approach their dietary intake, their exercise patterns, and then use this new tool properly this time to help them get where they need to get to. That’s the biggest thing - is this time around, let’s make sure that we do it right. Let’s make sure that you have proper follow-up. 15, 20 years ago, centers across the country would have patients come in, get some brief pre-op counseling, perform surgery, see the patient once or twice postoperatively, and then the patient was essentially on their own. Over the past years, our societies have recognized that patients really need that close follow-up and certainly in the first several years. But we see patients that have had surgery, as I said, sometimes 15, 20 or even longer years ago. Yeah, the benefits of a revisional bariatric procedure would be essentially the same as benefits of the original procedure. Patients should expect to lose a fair amount of their excess weight. That will depend greatly what they come with and what we convert them to. But they should expect to lose more weight with these procedures. They should expect to get better control of many of their medical problems. And then if the reason that they’re coming for revision has nothing to do with excess weight - let’s says there’s some issue with the prior surgery - they should expect us to be able to help them with that issue by re-creating more functional anatomy for them.
Host: Could you talk a little bit about the program for follow-up for bariatric patients here?
Dr. Shope: Sure. We see patients for their immediate post-op visit within 10 days to 2 weeks after the procedure, which is often, especially for somebody who just had revisional surgery - they might be in the hospital a day or two longer. So, it ends up being a week - give or take - after they leave the hospital. At the visit, they will see not only their surgeon but also our team of dieticians. Critical stuff, especially early on, as these patients are not only getting what their body needs from the standpoint of fluids but also the nutrition that they need to thrive and to heal their recent wounds from surgery. After that first visit, we see the patient, depending on how their doing, anywhere from the following week if they’re really struggling to get their nutritional needs in, or maybe as much as a month or so afterwards. From that visit we progress on, usually about 3 months and then about 6 months after that which brings us close to a year after surgery. And then yearly from that point on for a minimum of 5 years. And we always tell the patients that like anytime you have a problem that you think you need to be seen, you need to get in touch with us. Any abdominal issue. Any pain, nausea, vomiting. Any GI tract issue - we certainly need to hear about it. I have no problem with them contacting their other providers but we need to be involved in that process as well.
Host: So clearly, the follow-up is key in avoiding revisional surgery. What else can patients do to reduce their risk for potential revisional weight loss surgery?
Dr. Shope: Do their best to follow along the program we’ve developed, as have other centers across the country. I’ll say strict but I think very doable programs for the dietary progression afterwards. It’s certainly not something that any one of us would want to choose to be on forever, but if they follow the dietary progression afterwards and really make the changes that are necessary in their life, not only from an intake standpoint but from a physical activity standpoint, from removing the stressors or triggers in their lives that lead to food seeking behavior, making sure that if somebody else lives in the home with them that those people aren’t bringing in tempting foods and the like. So, they really need to address a lot of spheres in their lives. And, in addition to the follow-up that I already mentioned, we have the capacity to bring patients back for one-on-one visits with dieticians to review food journals. We can have them seek behavioral modification, psychiatry, these types of added measures to help them not need a revision.
Host: Is revisional weight loss surgery usually covered by insurance?
Dr. Shope: Revisional weight loss surgery usually is covered by insurance. Medicare does not like to cover it. But, if there’s compelling reasons to do so, they will. The other insurance companies generally will but most of the time patients have to recommit to the entire process - all the pre-operative program that’s necessary the first time.
Host: Could you share a success story from your practice?
Dr. Shope: Sure. We’ve had a number of patients do really, really well after revisional surgery. And again, some of these folks have done well initially. They just, over the long term, needed some extra help. The patients that come to mind include patients that have had, I’ll say, an issue with their previous surgery. We’ve had a few folks that have had sleeve gastrectomy, as I mentioned. One or two from our institution but several from within the city or elsewhere in the country that really have had severe, severe reflux and we’ve converted them to gastric bypass anatomy. The one woman, in particular, the next day was just so thankful that she didn’t have reflux anymore. Very simple, straightforward fix for her. That changes around a lot about how she has to approach things afterwards but we gave her proper counseling and she’s doing great from that standpoint. From the patients that just needed to lose more weight, we definitely have had folks that have been converted, most of them, I think, from lap bands, who just didn’t get everything they needed. And they gave it an honest effort—5, 7 years in some cases—even people that have come in for regular adjustments when they needed it with their lap bands. And we’ve converted them either to sleeve or to gastric bypass and then they’ve done very, very well with, not only getting rid of the weight, but addressing their medical troubles as well. I revised a patient who, his original bypass, the length of the bypassed intestine was about 50 centimeters. Now when he had his original procedure in the late ‘90s, and at that point in time, that was relatively standard of care. What I can tell you is that when I re-operated on him, the entire length of the small intestine was over 700 centimeters. So, he had a very small percentage of his intestine bypassed. And so, we gave him now a more appropriate length of bypass. In addition he also had a gastrogastric fistula, which is an abnormal connection between the pouch and the other part of the stomach, likely because when his original procedure was done, the type of stapler that was used is different than the one that we use today. That stapler didn’t actually separate the tissue. It just partitioned it. So, based on the instruments that were used, and the way that the surgery was done 10, 12 years ago, his procedure in today’s world would not have been what we do. Another guy, about a year ago now, he came to us after having had a procedure which was much more similar to the biliopancreatic diversion operation I talked about earlier. This was done in the early ‘90s. And his understanding from that point in time was that he actually had a gastric bypass operation. He was doing rather poorly from a nutritional standpoint. In other words, he wasn’t able to get what his body needs, despite having a very large pouch. The way that that procedure was done back in the ‘90s, they created a very large pouch for patients and then did a very long bypass. And so, despite him being able to eat a lot of food, which many of our patients aren’t able to eat a lot at one setting, he was not able to extract the calories and nutrition that he needed because of how long his bypass was. Because of how long ago that operation was done, I wasn’t able to get records for him so I didn’t know exactly what was done. But at surgery, when I eventually operated on him, I found, again, a very large stomach pouch and a very, very long bypass, which, again, may have been standard of care at the time, but certainly wasn’t something that we would do today and also was NOT helping this gentleman - he really needed from a nutritional standpoint. I actually ended up making his pouch a lot smaller so that he could eat less, but I substantially shortened his bypass so now his body’s gonna be able to get those calories and nutrients that it needs.
Host: Why should patients who are having some difficulties after previous surgery or who want to lose more weight after bariatric surgery come to MedStar Washington Hospital Center for revision?
Dr. Shope: Well, because it’s what we do. One of many things that we do in our program. We have certification through the American Society of Metabolic and Bariatric Surgery, through their metabolic and bariatric surgery quality assurance program (MBSAQIP). We take a lot of pride, actually, in that because it’s a certification that says we’re here and we do this and we do it well and we have the data to support that. We have the outcomes to support that. Not a lot of places around will do revisional surgery because it’s technically difficult sometimes. It’s a little bit more risky for the patients so you have to be willing to not only accept that risk WITH the patient but be able to identify it, be able to mitigate it, be able to minimize the problems that they can have with these things. So, it’s easy to do some of the straightforward cases. These more complex cases need to be at a place like ours where number one, we’ve got a program, we’ve got the accreditation and certification to back it up and we’ve got the experience. We’ve got several fellowship-trained surgeons. We’ve got two of us that have been doing bariatrics for more that 15 years. And we know how to take care of these problems.
Host: Thanks for joining us today, Dr. Shope.
Dr. Shope: Well, thanks again for having me.
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