Transforming With Gastric Sleeve Revision to Bypass Surgery

Gastric sleeve revision to bypass surgery is performed in obese patients who have not achieved the desired weight after sleeve gastrectomy (gastric sleeve).

It is also performed on patients who have intractable symptoms of GERD (gastroesophageal reflux disease) such as heartburn and nausea.

A gastric sleeve is usually the preferred first line of surgical treatment for most obese patients.

About a fifth of the patients who have had LSG (laparoscopic sleeve gastrectomy) will ultimately go for revision of Gastric Sleeve surgery.

Gastric Sleeve Revision to Bypass Surgery:

Morbidly obese people often opt for bariatric surgical procedures. It is obvious that the safest bariatric surgical procedure is usually the first choice of most patients.

However, the safest procedure may not be the most effective procedure for weight loss and curing other obesity-associated medical conditions like diabetes, hyperlipidemia, Sleep apnea, and PCOS.

Gastric Sleeve or Sleeve Gastrectomy or Laparoscopic Sleeve Gastrectomy is one of the safest procedures for weight loss. However, it is not very effective compared to Gastric bypass surgery.

It is not uncommon for a patient to opt for Gastric Sleeve Revision to Bypass Surgery if the results of the Gastric Sleeve are suboptimal.

After Gastric Sleeve, patients usually lose weight continuously for the first year. Although weight loss is maintained over a period of five or more years, some patients start to regain weight after the first year of sleeve gastrectomy.

It is estimated that about 0ne-fifth (19.7%) of the patients undergo gastric sleeve revision to bypass surgery after 7 years.

Most patients opt for revision to lose more weight or sometimes for the metabolic effects of gastric bypass surgery.

One option is re-sleeve gastrectomy as the stomach distends with time and the same procedure is repeated after some time.

Other options are revision to bypass surgery or adding the novel GLP-1, Weogvy or Ozempic, or the Dual GLP/GIP analog, Mounjaro (Tirzepatide).

Even in patients undergoing certain gastric bypass surgeries like biliopancreatic diversion and duodenal switch procedures, sleeve gastrectomy is usually the first step of these bypass surgeries.

The success rates of gastric sleeve revision to bypass surgery are:

• 80% to 90% in the first few months to years and
• 70% in the long term.

However, the cost is 30 to 50% higher than gastric sleeve surgery.

When to Opt for Gastric Sleeve Revision to Bypass Surgery:

The three main reasons people opt for a gastric sleeve revision to bypass surgery are:

• Inadequate weight loss
• Quick weight regain
• Complications after gastric sleeve such as GERD.

Inadequate weight loss:

Inadequate weight loss is one of the most common causes of gastric sleeve revision to bypass. Although gastric sleeve surgery is associated with significant weight loss, some patients do not achieve the desired results.

Usually, with gastric sleeve surgery, the expected weight loss is:

• Weight loss after 3 months is 30% of the baseline body weight
• Weight loss after 6 months is 50% of the baseline weight
• Weight loss after 1 year is 70% of the baseline weight

Patients usually expect to lose about half of their body weight. However, if the weight loss is minimal and not as per the patient’s expectations, then gastric sleeve revision to bypass is usually performed.

Weight regain (Recidivism) after Gastric Sleeve Surgery:

Weight regain is common. However, most patients who regain weight, are non-compliant with the dietary advice and do not put effort to stop weight regain.

Weight regain is common after 5 to 7 years of the surgery but that is not usually significant weight regain. A slow weight regain is expected because of a sedentary lifestyle and overeating or eating high-carb and high-glycemic-index foods.

Some patients who regain weight quickly do so because of pouch dilation that allows them to eat more. A quick weight regain is usually another reason for gastric sleeve revision to bypass surgery.

To avoid weight regain after Gastric Sleeve, one should focus on the reasons for weight regain and try to manage them.

Here is a list of the causes of weight regain after gastric sleeve surgery:

Why do you regain weight quickly after Gastric Sleeve?

1. Pouch dilatation

Pouch dilation is one of the most common reasons for weight regain after gastric sleeve surgery. This results in a quick regain of weight after surgery.

Most patients who have pouch dilation after gastric sleeve consume more than their recommended diet. Binge eating is one of the problems of such patients.

To avoid pouch dilation and weight regain, it is recommended to take small frequent meals rather than one or two larger meals.

People who have a craving or binge eating syndrome can benefit from the addition of GLP-1 and dual GLP/GIP analogs.

GLP-1 analogs (Ozempic, Rybelsus, and Wegovy) and dual GLP-1/GIP analogs ( Tirzepatide – Mounjaro) suppress cravings and make you feel full all the time resulting in significant weight loss in obese patients.

2. Body metabolism working against you.

Sometimes, as the food intake of a person is reduced abruptly, as occurs after a weight loss surgery or gastric sleeve surgery, the body tries to adapt to the new low-food low-calorie situation by lowering the basal metabolic rate.

Slow metabolism is one of the major mechanisms of weight gain. It is commonly seen in people with hypothyroidism and genetic obesity.

How to boost your metabolism to stop weight regain after gastric sleeve surgery?

The metabolic rate of a body is controlled by stress hormones, adrenaline and nor-adrenaline, and thyroid hormones.

It is important to get tested for hypothyroidism. Thyroxine replacement in hypothyroid patients can prevent weight regain by boosting metabolism.

To increase the metabolic rates of the body, one can increase the intake of green tea, coffee, and caffeinated beverages.

Alternatively, phentermine is an FDA-approved weight loss drug. It works by boosting the metabolic rates of the body. People with a slow metabolic rate can benefit from phentermine/ topiramate (Contrave).

3. Choosing the wrong Procedure:

It is important to choose the right procedure for the right person. Gastric Sleeve surgery may not be the best option for some patients.

Choosing the wrong procedure may result in quick weight regain. In addition, they may not lose significant weight as they desire.

For super-obese people and those with multiple obesity-associated complications like diabetes, hyperlipidemia, and sleep apnea, gastric bypass may be the best option from the start.

Choosing the right procedure from the start may prevent surgery and revision to bypass.

4. Anatomical Changes:

Sometimes things are not under your direct control. You are compliant with the recommended diet and still gaining weight.

This happens when the anastomosis lumen widens up leading to the accommodation of larger meals, resulting in weight regain.

5. Weight regain is natural as life goes on:

Weight regain is common after 5 to 7 years. People who have had a bariatric surgical procedure a long-time ago regain weight because the stomach stretches out with time and adapts to accommodate more food.

In addition, people go back to their normal routine eating habits and start gaining weight.

Some of the weight regain in such patients can be prevented by doing regular exercise, eating less, eating a low-calorie diet and more fiber, or using some of the novel weight loss drugs.

6. Stress-Induced weight regain:

Weight gain is common in people with depression and other psychiatric illnesses. Depression and stress may cause a person to eat more despite being full.

In addition, drugs to treat depression may cause weight gain. It has also been found that people who undergo weight loss surgery are more at risk of suicide and depression.

How to manage weight regain with antidepressants?

It is best to get help from your doctor. With a few exceptions, all antidepressant drugs are associated with weight gain.

Prozac (Fluoxetine) is considered weight neutral or may cause some weight loss while Bupropion is a weight-loss drug. It has been approved by the FDA as a weight loss drug by the brand name of Qsymia that contains Bupropion and Naltrexone.

7. Incomplete resection or a faulty procedure:

The capacity of the stomach to accommodate food is not markedly reduced if the fundus of the stomach is not resected completely.

This happens when the surgeon performing surgery does not recognize a hiatal hernia or for some other reason. The pouch size is larger than the standard and hence it has a larger capacity to store more food.

What to do?

The surgeon must perform an upper GI endoscopy before gastric sleeve surgery to identify the hiatal hernia.

Secondly, the volume of the resected stomach should not exceed a maximum of 200 to 300 ml after the surgery.

Some people can’t tolerate GERD:

GERD (gastroesophageal reflux disease) is a common complication of gastric sleeve surgery.

People with preexisting GERD may develop intractable symptoms and may opt for revision to gastric bypass surgery.

Gastric bypass surgery is not associated with GERD. This could be one of the reasons why patients opt for gastric sleeve revision to bypass surgery.

Option Available for Gastric Sleeve Revision to Bypass Surgery:

Do you have any options to opt for when you consider gastric sleeve revision to bypass surgery?

Yes. So there are four types of bypass procedures. Your doctor is the best person to discuss all the Pros and Cons of each procedure with you.

Here is a list of the four gastric bypass procedures that are commonly practiced. They are mentioned from the least invasive to the most invasive ones:

1. Mini-Gastric Bypass Surgery (least Invasive of all the bypass procedures)
2. Roux-en-Y Gastric Bypass Surgery (Invasive)
3. Biliopancreatic Bypass Procedure (More invasive)
4. Duodenal Switch (The Most Invasive)

Mini-Gastric Bypass Surgery:

Mini-Gastric Bypass Surgery or MGB is similar to the Roux-en-Y Gastric Bypass procedure but it is a little simpler than Roux-en-Y gastric bypass surgery.

MGB (Mini-Gastric Bypass) is performed by creating a stomach pouch with the help of a linear stapler. This is followed by the anastomosis of the small intestine directly with the stomach pouch without resection of the gut at any point.

Although MGB (mini gastric bypass surgery) is the least invasive, it has a similar rate of complications as Roux-en-Y Gastric Bypass Surgery except for per-operative bleeding that may be minimal in this procedure compared to Roux-en-Y Gastric Bypass Surgery.

Roux-en-Y gastric bypass surgery:

In the procedure, the stomach pouch is created by resecting part of the stomach. This is followed by resection of the small intestine.

The distal loop of the resected small intestine is anastomosed with the stomach pouch and the proximal end is anastomosed back with the small intestine distally.

Complications of Roux-en-Y Gastric Bypass Surgery:

Complications associated with the Roux-en-Y gastric bypass procedure are related either to the surgery itself or because of the effects of the surgery on the body.

1. Anastomotic leaks

An anastomotic leak in any procedure is a nightmare for surgeons. This is because of its association with increased mortality and morbidity.

Patients who develop an anastomotic leak may have localized peritonitis or may present with generalized peritonitis. Treatment is surgical correction and broad-spectrum intravenous antibiotics.

2. Anastomotic stricture

Strictures can develop after gastric bypass surgery. The timing may vary from early to late. Strictures usually develop in gastro-jejunostomy but may occur at any anastomotic site.

Treatment depends on the location of the strictures. In some cases, surgical correction may be needed whereas, in others, an endoscopic approach may be sufficient.

3. Marginal ulcer:

This develops at the site of gastrojejunostomy anastomosis. Treatment is with antacids and acid-suppressing drugs like Prilosec (Omeprazole).

4. Bleeding:

Bleeding can occur during or after the surgery. It may vary from minimal bleeding to massive bleeding that requires urgent transfusion and surgery.

5. Nutritional deficiency:

As Roux-en-Y gastric bypass surgery is malabsorptive surgery, the patient will develop a nutritional deficiency if supplementation and preoperative assessment is not done properly.

Correction of nutritional deficiency is necessary as it will have a negative effect on the patient’s health.

Biliopancreatic Bypass Surgery:

This is a more complex procedure than Roux-en-Y gastric bypass surgery. In this procedure, the first step is the sleeve gastrectomy.

In the biliopancreatic bypass surgery, about a100 cm of the distal part of the small gut is resected and the distal loop is anastomosed with the stomach while the proximal loop is anastomosed with the ileum near the cecum.

Food will be digested and assimilated in the 100 cm loop of the small gut only. Because most of the small bowel is resected, it is associated with tremendous weight loss.

Complications of biliopancreatic bypass surgery:

1. Anastomotic leaks
2. Anastomotic strictures
3. Nutritional deficiency (Protein malnutrition and nutritional deficiency of nutrients and vitamins are the main concerns that lead to the reversal of this surgery at some point).

Duodenal switch:

This is the same as biliopancreatic gastric bypass except that the pylorus of the stomach is retained and the intestinal loop is anastomosed with the pylorus instead of the stomach pouch.

The main benefit of the duodenal switch over biliopancreatic surgery is that it is least likely to be associated with dumping syndrome.

The second difference is the relatively long length of the common loop. This allows more time for food to b mixed and absorbed.

Complications of the Duodenal Switch are similar to biliopancreatic diversion.

Which is the best Gastric Sleeve Revision to Bypass Surgery Option:

After deciding to go for gastric sleeve revision, the main concern is which procedure to opt for. We have to go for any of the following surgical options:

• Repeat sleeve gastrectomy
• Gastric Sleeve Revision to Mini-Gastric Bypass Surgery
• Gastric Sleeve Revision to Rou-en-Y Gastric Bypass Surgery
• Gastric Sleeve Revision to Biliopancreatic Diversion
• Gastric Sleeve Revision to Duodenal Switch

Alternatively, one can add a weight loss medicine, especially Wegovy, Ozempic, and Mounjaro.

Choosing the Right Procedure.

Before considering sleeve revision to bypass surgery, re-evaluate your dietary practices and calorie intake.

Go for dietary and lifestyle modification first. Consider going for surgery only after you are exhausted as redo surgery is difficult to perform.

The list of bypass surgeries includes many options but choosing the correct procedure is essential. Revision of gastric sleeve to bypass is safe and effective. The patient can expect to lose 60% of excess weight from it.

Selecting the right kind of surgery depends upon many factors including:

• Previous surgery
• Your Weight
• Comorbid conditions
• The expertise of the surgeon

Choosing Sleeve Revision to Mini Gastric Bypass Surgery:

This is the most simple of all the bypass procedures and does not involve a lot of expertise. You can choose MGB as your best option if you are just missing your target weight.

MGB is associated with little weight loss compared to other bypass surgeries. Furthermore, weight loss following MGB is very slow.

Sleeve Revision to Roux-en-Y Gastric Bypass Surgery:

Revision of gastric sleeve to Roux-en-Y gastric bypass is the gold standard. It is the safest and associated with significant weight loss.

The weight loss associated with Roux-en-Y bypass surgery is not as much as can be seen in patients undergoing duodenal switch.

However, because of its simplicity and safety, it is preferred over duodenal switch surgery. Within 12 months of the sleeve revision, Roux-en-Y bypass surgery will provide up to 70% of the excess weight loss.

Weight loss is the most rapid during the first 3 months. It can cure obesity in 100 % of obese patients who are strictly compliant with diet and exercise.

Additional benefits of this procedure are that it has a low risk of weight regain and a lower risk of vitamin and nutrient deficiency.

Sleeve revision to Duodenal switch:

This procedure provides the maximum weight loss compared to other procedures. However, because of its complexity and rarity of expertise, this procedure is the least preferred.

It has numerous complications because of which reversal of procedure is sometimes necessary.