Reoperations and revisions in bariatric surgery.

With the growing number of bariatric procedures being performed in the US, it is important for bariatric and general surgeons to understand the potential need for reoperations and revisions after the various types of bariatric operations. A reoperative bariatric surgery panel convened at the annual meeting of The Society of American Gastrointestinal and Endoscopic Surgeons in Las Vegas, NV, on April 20, 2007. The panel was composed of bariatric surgeons with extensive experience in reoperation and revisional bariatric surgery. The main topics discussed were the principles of reoperative surgery and the techniques and outcome of reoperation for late complications and revisional surgery for failed weight loss. Dr. Michael Sarr opened the forum with a presentation on the fundamentals of revisional and reoperative bariatric surgery. Revisional bariatric surgery refers to reoperative surgery for inadequate weight loss. Reoperations refer to reoperative surgery for late complications arising from bariatric operations such as gastroplasty, laparoscopic adjustable gastric banding (Lap-Band), duodenal switch, and Roux-en-Y gastric bypass. He emphasized that reoperative surgery requires a thorough preoperative work-up and operative strategies, and while all general surgeons should have the basic knowledge in the management of post-bariatric complications and emergencies, elective revisional operations for failure of weight loss should be performed by experienced bariatric surgeons. Dr. Philip Schauer discussed one of the most common late complications after Roux-en-Y gastric bypass – intestinal obstruction. He emphasized that closure of all mesenteric defects is highly recommended to prevent internal hernias. Additionally, the ante-colic, ante-gastric route of the Roux limb reduces the incidence of internal herniation and essentially eliminates hernias at the transverse mesocolon defect. Early recognition and surgical reexploration in patients suspected of having a bowel obstruction after Roux-en-Y gastric bypass is the key to preventing a catastrophic complication from an internal hernia such as ischemic bowel. In my presentation, another common complication after Roux-en-Y gastric bypass was presented: marginal ulceration. Most anastomotic ulcers can be managed with conservative treatment such as initiation of proton pump inhibitors, cessation of smoking, endoscopic removal of foreign bodies, or cessation of NSAID use. An upper gastrointestinal contrast study should be performed to evaluate for a concomitant gastrogastric fistula. The presence of a fistula will require take down of the fistulae and revision of the gastrojejunostomy. In cases of marginal ulceration without a fistula and refractory to medical therapy, surgical excision of the anastomosis, encompassing the ulcer(s) region, is the definitive treatment. The laparoscopic approach to excision of the gastrojejunostomy with reconstruction is technically feasible and safe for the management of refractory marginal ulcerations. Dr. Kelvin Higa presented on the role of more restrictive operations for patients presenting with inadequate weight loss or weight recidivism after gastric bypass. Possible Presented at the annual meeting of The Society of American Gastrointestinal and Endoscopic Surgeons in Las Vegas, NV, on April 20, 2007.