Sleeve Gastrectomy Revision Surgery

Obesity is an important health issue worldwide and often leads to chronic diseases. In this context, bariatric surgery offers effective and lasting solutions for weight loss, especially in cases of severe obesity. Sleeve gastrectomy stands out among these operations for its simplicity and reliability. However, long-term weight regain may be inevitable for some patients, necessitating revision surgeries to address post-operative issues.

Revision Surgery Options Against Weight Regain

Weight regain is a significant problem encountered after bariatric surgery, particularly in patients with severe obesity. To combat this issue, various revision surgery methods have been developed. Weight regain after sleeve gastrectomy revision surgery can be related to the increase in stomach volume. This usually occurs due to the re-expansion of the stomach pouch. Studies have shown the effectiveness of revision surgery techniques to address this issue.

The main revision methods used for weight regain after bariatric surgery are:

• Resleeve Gastrectomy (ReSG): Repeating the initial operation to re-narrow the expanded stomach pouch.
• Roux-en-Y Gastric Bypass (RYGB): Preferred for patients with gastroesophageal reflux disease. It is also effective against weight regain associated with stomach pouch expansion.
• Duodenal Switch (DS): A more complex procedure that combines malabsorptive and restrictive features. It is usually seen as a last resort.

Revision surgeries aim to address issues such as increased stomach volume and expanded stomach pouch. Additionally, revision surgeries are designed to correct anatomical changes that occur after bariatric surgery and increase the risk of weight regain.

Revision Options for T2DM Recurrence After Sleeve Gastrectomy

After sleeve gastrectomy, some patients may experience a recurrence of type 2 diabetes mellitus (T2DM). In such cases, revision surgeries become crucial. There are various surgical options available for patients experiencing diabetes recurrence. The aim of revision surgeries is to improve metabolic status and prevent progressing complications.

The revision options are:

• Repeat Sleeve Gastrectomy (SG): Considered when the initial operation is insufficient.
• Roux-en-Y Gastric Bypass (RYGB): Effective in controlling metabolic syndrome and supports diabetes remission.
• Duodenal Switch (DS): Preferred for severe T2DM cases and offers effective results.

RYGB has more pronounced neurohormonal effects compared to sleeve gastrectomy, making it more successful in diabetes control. DS shows high effectiveness through the foregut bypass mechanism. Both methods can provide greater weight loss than SG, supporting metabolic improvement.

Revision surgeries are particularly important for patients with a short duration of diabetes and good beta-cell function. These patients may show a better metabolic response after revision. However, the necessity for revision should be evaluated based on individual health conditions and the results of the initial operation.

GERD Revision Solutions After Sleeve Gastrectomy

Revision approaches for the treatment of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (LSG) are continuously evolving to meet increasing patient needs. Managing GERD symptoms and improving quality of life have become significant goals in obesity surgery. In such cases, revision surgeries are vital for controlling symptoms.

Preoperative endoscopic evaluations play a critical role in identifying potential GERD cases. This can help prevent complications that may arise after LSG. The following surgical techniques can be applied to manage GERD:

• Roux-en-Y Gastric Bypass (RYGB): Observed to be effective in reducing reflux symptoms. RYGB reduces stomach volume and minimizes acid exposure.
• Hiatal Hernia Repair (HHR): Used to treat hiatal hernias performed with or after LSG. However, some studies show that HHR has limited impact on GERD.
• Endoscopic techniques: Innovative endoscopic techniques like the Stretta procedure and EndoStim LES Stimulation System can be used to reduce GERD symptoms. These techniques offer minimally invasive approaches, speeding up the patient’s recovery process.

These revision procedures play an important role in alleviating and potentially improving GERD symptoms. However, each patient’s condition is different, and individual needs and previous surgical interventions should be considered when deciding on the appropriate revision treatment. Factors such as the patient’s health status, previous surgeries, and the severity of symptoms are critical in determining the appropriate revision strategy.

Revision Surgeries for Strictures After Sleeve Gastrectomy

The need to diversify treatment methods arises due to complications such as strictures after sleeve gastrectomy. Strictures typically present with symptoms like difficulty eating, nausea, and vomiting. Endoscopic dilation is preferred as the initial intervention. This procedure involves the use of endoscopic tools to apply dilators to the narrowed area, often yielding successful results.

If endoscopic methods prove insufficient, surgical revision methods are employed. Surgical revisions have the potential to permanently resolve the stricture problem and employ various techniques:

• Laparoscopic Roux-en-Y Gastric Bypass (RYGB): This method creates a new stomach pouch away from the narrowed area, allowing food to pass without being affected by the stricture.
• Wedge Gastrectomy: Involves the surgical removal of the narrowed area, directly opening the passageway.
• Seromyotomy: This method aims to widen the narrowed area by making incisions. However, it carries a high risk of complications, particularly stomach leakage.

Among surgical revision options, laparoscopic RYGB remains the most popular method. This technique stands out for its broad usage and effective results. However, the potential risks and benefits of each method should be carefully evaluated:

• Laparoscopic RYGB: Bypasses the stomach, completely excluding the narrowed area.
• Wedge Gastrectomy: Offers quick and effective results by directly removing the narrow area.
• Seromyotomy: A riskier approach with a high risk of serious complications such as stomach leakage.

Revisional Bariatric Surgery Approaches After Gastric Leak

Gastric leak is a serious complication encountered after laparoscopic sleeve gastrectomy. If it occurs within the first week, it is referred to as “acute.” If it occurs after the first week but within six weeks, it is considered “early,” and after six weeks, it is classified as “late.” Leaks lasting more than twelve weeks are considered “chronic.” Early diagnosis is vital for patients. The treatment process varies depending on the stage and severity of the leak.

Initially, endoscopic interventions are recommended. These interventions include:

• Endoscopic stent placement,
• Fibrin glue injection,
• Percutaneous drainage,
• Use of hemoclips.

Most early leaks can be successfully treated with these methods. However, chronic leaks usually require more complex surgical interventions. Three main surgical approaches stand out for managing chronic leaks:

• Laparoscopic Roux-En-Y Esophago-Jejunostomy (LRYEJ),
• Roux-en-Y Gastric Bypass (RYGB),
• Total or near-total gastrectomy with esophagojejunal anastomosis.

Each method has its own advantages and risks. LRYEJ anastomoses the fistula area to the small intestine loop. This process is completed with distal jejunojejunostomy for bile diversion. RYGB reduces intragastric pressure, aiding fistula healing. This method is not preferred in cases of severe peritonitis and hemodynamic instability. Total gastrectomy is used as a last resort for chronic leaks and is effective in overcoming challenges such as inflammation, fibrosis dissection, and adhesions.

These surgical methods are considered as a transition process to other bariatric procedures in cases of complications and inadequate response. The success of the treatment is closely related to the correct application of the techniques used and the appropriate guidance based on the patient’s condition. The patient’s overall health status and previous surgical interventions are taken into account when determining the revisional surgery option.

Multiple Revisional Bariatric Surgeries

Revisional bariatric surgery comes into play when the initial operation fails. After a failure, revisional surgery is shaped based on the patient’s current physiological condition and past surgical outcomes. These types of surgeries generally carry higher risks and require careful evaluation. The anatomical and metabolic changes in patients create unique challenges for surgery. Patients who have to undergo multiple bariatric operations face increasing risk and complexity with each new intervention. These operations:

• Require high technical skill,
• Demand careful assessment and

  patient management.

As a result, multiple revisional bariatric surgeries become necessary for patients who fail to achieve the expected weight loss or control metabolic diseases.

Laparoscopic Sleeve Gastrectomy (LSG) and Revision Surgery in East Asia

LSG has recently become a prominent treatment method in East Asia. This procedure has become widespread in many countries, especially Japan. Local research on the effectiveness and long-term outcomes of this procedure is increasing. National surveys conducted in Japan have revealed the positive effects of this procedure on obesity and related diseases. Studies in South Korea also confirm the short- and medium-term effects of LSG.

• LSG provides significant weight loss among Asian patients with obesity,
• Research in Japan and South Korea shows that LSG is an effective method,
• Low revision rates after LSG indicate the success of this method.

The need for revision surgery is usually triggered by long-term weight regain or recurrence of metabolic syndromes. Corrective operations performed after LSG aim to improve the patient’s health condition. In particular, the %TWL cut-off point set for diabetes remission in Japan plays a critical role in determining treatment strategies. Additionally, the effectiveness of various procedures has been compared in the management of conditions such as hypertension and dyslipidemia.

Results and Expectations

Laparoscopic sleeve gastrectomy (LSG) stands out with its low morbidity and mortality rates. This method is also prominent for its cost-effectiveness. However, there is limited data on the long-term outcomes of LSG. Moreover, the need for revision surgery after LSG is increasing. The main reasons for revision surgery include:

• Insufficient weight loss,
• Gastroesophageal reflux disease (GERD),
• Strictures,
• Gastric leak (GL),
• Persistent metabolic syndrome.

Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is considered an effective approach in revision surgery. New techniques like robot-assisted LSG and endoscopic sleeve gastroplasty (ESG) also show promise. Especially ESG is preferred for its minimally invasive feature and reduced risk of side effects by shrinking the stomach reservoir.