Gastric Bypass Revision Surgery -
5 Options

Roux en Y gastric bypass surgery is successful for the majority of patients, but gastric bypass revision surgery may be necessary for patients who experience significant weight regain after hitting their low weight.1

When Gastric Bypass Revision Is Appropriate

The most common reason patients consider gastric bypass revision is weight-related… either not enough was lost following surgery or too much was gained back.2

Research shows that up to 20% of patients who were morbidly obese prior to their initial surgery and up to 35% of patients who were super obese have gained back more than 50% of their excess weight after 10 years.3 Sometimes this is the result of internal issues that require surgical revision while other times inappropriate diet or exercise is the culprit.

Gastric bypass revision surgery can carry risks just like your initial surgery, so it is important that you follow your surgeon’s orders exactly to avoid a second surgery if possible.

To this end, your surgeon will want to rule out diet or exercise problems before moving forward with another procedure and will likely take the following two steps:4

  1. Rule out diet as the cause of insufficient weight loss or weight regain
    • Work with your dietitian to very carefully track what you eat using a handwritten or online free diet journal.
    • Work with your psychologist to determine whether any emotional issues could be causing your diet or exercise goals to veer off-track.
  2. Rule out exercise as the cause
    • Your dietitian can use a special device called an indirect calorimeter (see video below) to test your basal metabolic rate (BMR), which is the amount of energy your body burns when you are resting.

      Patients with an extremely low BMR could have issues with weight loss even if pouch size and dietary habits are where they should be. Your base metabolic rate can be increased if you add more lean body mass (muscle), so if low BMR is a problem your surgeon will most likely have you work with a personal trainer to properly adjust your exercise after gastric bypass surgery.

After diet and exercise problems are ruled out, your surgeon will want to check your stomach pouch size and the opening between your stomach and your small intestines (also called your “stoma”). If either is too large (or has stretched), it may be the cause of your post-surgery weight loss problems.5

Your surgeon has a few ways to check this:

  • Upper Gastrointestinal Tract Radiography (also called an “upper GI”) – Your surgeon will have you drink a special colored dye while taking an x-ray in order to see your digestive tract “in motion”.
  • Endoscopy – After applying a numbing spray and/or medication, the surgeon will pass a tube with a camera through your mouth, down your esophagus and into your stomach to directly evaluate the size of your pouch and stoma.
  • Eating test – Your surgeon will measure the amount of food you can eat before feeling full.

In addition to determining whether your pouch and stoma size are an issue, the upper GI and endoscopy can detect issues such as staple line problems, gastrogastric fistula, esophageal abnormalities and Roux limb abnormalities.6

If stomach stretching or stoma enlargement is identified, a revision surgery may be your only option to halt or reverse the weight regain.

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5 Types of Gastric Bypass Revision Surgeries – Explanation, Cost, Risks & Recovery

In order to surgically facilitate weight loss, your surgeon will likely choose one of five ways to reduce your pouch and/or stoma size back to what it was (or what it should have been) after your initial procedure.

A reduced pouch size will cause your stomach to hold less, making you feel full sooner. A reduced stoma size will cause your stomach to drain more slowly, prolonging your feelings of fullness.

Sure that your original surgeon is right for the job?

Before getting into the five types of gastric bypass revision procedures, consider whether your original surgeon is right for the job.

If you took the proper steps towards finding, evaluating, interviewing and choosing your original weight loss surgeon, if the costs were right AND if you felt good about your experience, stick with your original team.

If you didn't interview multiple surgeons or if something "just felt off" with your original team, it may be a good idea to interview another qualified surgeon to compare their abilities, team, services and cost.

Click here to find and schedule an in-person seminar or one-on-one consultation with another qualified weight loss surgeon in your area.

The five most common gastric bypass revision procedures include:

  1. Shrink the stoma by injecting a sclerosant
  2. Make the stomach pouch or stoma smaller using a device to create internal "folds"
  3. Add adjustable gastric band (convert to lap band surgery)
  4. Lengthen Roux limb
  5. Convert to duodenal switch

1. Shrink the stoma by injecting a sclerosant ("sclerotherapy")

Your surgeon may decide that injecting a sclerosant (sodium morrhuate) into the stoma (opening between the stomach and small intestine) is the best way to address the relatively common problem of stoma dilation.

The injections - which will most likely need to be done over the course of two or three procedures - attempts to create scarring that reduces the stoma’s size.

One study showed that 64% of patients lost at least 75% of their weight regain after their injections.11 The only complication that occurred was symptoms of stomal stenosis that required the stomach to be stretched back out with the use of a special balloon.

Another study revealed that out of 231 patients who underwent 575 sclerotherapy sessions:12

  • 12 months from the last sclerotherapy session, weight regain stabilized in 78% of the patients
  • Patients who underwent two or three sclerotherapy sessions had much higher rates of weight regain stabilization than those who underwent a single session
  • The average sclerotherapy patient lost 10 pounds in six months
  • There were 'high responders' who lost an average of 26 pounds, which was 61% of the weight regain
  • Those who had higher regain after bariatric surgery responded better to sclerotherapy

The procedure does carry a low risk of minor complications including:

  • Bleeding (2.5% of patients)
  • Abdominal pain (0.5%)
  • Small ulcers (1%)
  • Transient, self-limited diastolic blood pressure elevation (11%)

Due to the relatively high risk of blood pressure elevation, patients with cardiac risk factors should most likely stay away from this procedure.

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2. Make the pouch smaller by passing a device through the mouth and into the pouch.

Two relatively new procedures – the StomaphyX and ROSE procedures – re-tighten the stomach without incisions by inserting special tubes through the mouth, down the esophagus and into the stomach pouch and then creating permanent folds (also called “plications”) around the stoma and within the pouch.

The two procedures differ in terms of the specific equipment and technique used to create the folds:

ROSE Procedure ($8,000 to $13,000)

When conducting the ROSE procedure (“Revision Obesity Surgery Endoscopic” or "Restorative Obesity Surgery, Endolumenal", depending on who you ask), the surgeon creates the folds manually using special ‘graspers’ and holds them in place with sutures and tissue anchors.

As explained in the video below, the nature of the procedure and the equipment used allows the surgeon to either narrow the stoma, reduce the pouch size or both.

Due to the newness of the procedure, limited studies exist. Following were the short-term results of two initial studies:

Study
# of patients Weight Loss Complications Year of Study
Reference: A, B
Study A 20 85% “success rate” – after 3 months, successful patients lost 8.8 kg of the 13 kg that they had regained prior to gastric bypass revision surgery No major complications 2009
Study B 116 88% of patients stopped regaining weight and lost an average of 18% of their excess body weight 6 months after the procedure n/a 2009
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StomaphyX (also $8,000 to $13,000)

In the StomaphyX procedure, the surgeon creates the folds using a special device that suctions the skin fold in then inserts an H-shaped fastener to hold the fold in place.

Due to the limitations caused by the device, StomaphyX can only be used to reduce pouch size – it cannot be used to shrink the stoma (see our StomaphyX Procedure page for more information).

However, by strategically placing the folds, the surgeon can shrink the diameter of the stomach thereby slowing the food that passes through it.

The following study demonstrated effective weight loss and resolution of minor health issues after one year with no major complications:

Study
# of patients Weight Loss & Health Improvement Complications Year of Study
Gastric Bypass Revision Reference: C
Study C 39 1 year – percentage of excess weight loss was 19.5%

Chronic diarrhea was resolved in 3 patients.

Gastroesophageal reflux disease improved in 8 patients.
No major complications.

Minor complications included a sore throat lasting less than 2 days in 87% of patients and epigastric (anterior walls of the abdomen) pain lasting a few days in 77% of patients.
2009

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ROSE & StomaphyX Additional Similarities - Procedure Time, Risk, Recovery, Cost & Financing

Both the ROSE and StomaphyX procedures take around 30 minutes to perform and most patients are fit to leave the hospital either the day of or the day after the surgery. Since there are no incisions, you should be ready to get back to your normal life within a day or two, although you may have a sore throat and abdomen for a few days following surgery.

The lack of incisions also drastically reduces your risks, although bleeding, perforation and the standard risks that go along with anesthesia are present.

Following surgery, your surgeon will put you back on a bariatric diet that was similar to what you were on after your initial procedure. Most patients transition back to their normal post-surgery diet no later than 6 weeks after the procedures.

From a financial perspective, except in rare circumstances when the procedure is medically necessary (not being received only for weight loss purposes), it is unlikely that insurance will cover either option.

However, there are several weight loss surgery financing options available to help pay for the $8,000 to $13,000 cost of treatment.

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3. Addition of adjustable gastric band (lap band surgery)

Two studies directly evaluated the effect of inserting an adjustable gastric band (lap band) following failed gastric bypass surgery:

  • Study 1 included 11 patients who, on average, received gastric bypass surgery 5 ½ years earlier. Their mean body mass index dropped from 43.4 to 37.1 (additional excess weight loss of about 21%).7
  • Study 2 evaluated 22 patients and saw a drop in excess weight of 47% after five years.8
  • Study 3 compiled seven studies with 94 total patients who experienced between 55.9% and 94.2% excess weight loss 12 to 42 months after the placement of the band. About one in five of these patients developed long-term complications that required another operation.13

You should expect the procedure, costs, health benefits and potential complications to be similar to having lap band surgery as an initial procedure.

See our Adjustable Gastric Banding page for more information.

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4. Lengthen the Roux limb

This procedure converts a proximal (conventional) Roux-en-Y gastric bypass to a distal Roux-en-Y gastric bypass. It is usually only considered when the patient has a very low base metabolic rate and continues with poor weight loss results despite an augmented exercise program.

While this conversion should be effective for weight loss, it will open you up to increased risks - far more than with any other procedures. For example, one study reported a 15% leak rate following revision surgery.9

For this reason, this procedure is not a standard primary approach for weight loss surgery and is why many surgeons feel that it is inappropriate even for the failed gastric bypass patient.

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5. Conversion to Duodenal Switch

Patients requiring gastric bypass revision surgery - especially patients who were super obese prior to gastric bypass surgery (50+ BMI) - may find a conversion to duodenal switch surgery to be the best option.

For example, one study evaluated 12 patients undergoing a conversion from Roux-en-Y gastric bypass to a duodenal switch. The patients had an average original BMI of 53.9, an average low BMI after gastric bypass of 31.6 and an average pre-conversion BMI of 40.7. About one year after revision surgery, their average BMI was 31 (63% excess weight lost).10

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References for Gastric Bypass Revision Surgery

  1. Nicolas V. Christou, MD, PhD, Didier Look, MD, and Lloyd D. MacLean, MD, PhD. Weight Gain After Short- and Long-Limb Gastric Bypass in Patients Followed for Longer Than 10 Years. Ann Surg. 2006 November; 244(5): 734–740.
  2. Behrns K, Smith C, Kelly K, Sarr M. Reoperative bariatric surgery—Lessons learned to improve patient selection and results. Ann Surg 1993;218:646–53.
  3. Nicolas V. Christou, MD, PhD, Didier Look, MD, and Lloyd D. MacLean, MD, PhD. Weight Gain After Short- and Long-Limb Gastric Bypass in Patients Followed for Longer Than 10 Years. Ann Surg. 2006 November; 244(5): 734–740.
  4. Brethauer S, Nfonsam V, Sherman V, et al. Endoscopy and upper gastrointestinal contrast studies are complementary in evaluation of weight regain after bariatric surgery. Surg Obes Relat Dis 2006;2:643–50
  5. Catalano MF, Rudic G, Anderson AJ, Chua TY. Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision. Gastrointest Endosc. 2007 Aug;66(2):240-5. Epub 2007 Feb 28.
  6. Manish Parikh, MD, Marc Bessler, MD. Revision Procedures for Failed Gastric Bypass. Bariatric Times. Sept 2007. Available at: http://bariatrictimes.com/2007/09/10/revision-procedures-for-failed-gastric-bypass/
  7. Ryan M. Gobble, et al. Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass. Surgical Endoscopy. Volume 22, Number 4, 1019-1022, DOI: 10.1007/s00464-007-9609-x
  8. Marc Bessler, et al. Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass—intermediate results. Surgery for Obesity and Related Diseases - January 2010 (Vol. 6, Issue 1, Pages 31-35, DOI: 10.1016/j.soard.2009.09.018)
  9. Keshishian A, Zahriya K, Hartoonian T, Ayagian C. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Obes Surg 2004;14:1187–92.
  10. Parikh M, et al. Laparoscopic Conversion of Failed Gastric Bypass to Duodenal Switch. February 2008. Department of Surgery, Mount Sinai Medical Center, Miami Beach, Florida.
  11. Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision Marc F. Catalano, Goran Rudic, Alfred J. Anderson, Thomas Y. Chua Gastrointestinal Endoscopy - August 2007 (Vol. 66, Issue 2, Pages 240-245, DOI: 10.1016/j.gie.2006.06.061)
  12. Helwick, Caroline. Sclerotherapy Stabilizes Weight Regain After Gastric Bypass. Gastroenterology & Endoscopy News. Dec 2011, Volume 62:12.
  13. Salvage banding for failed Roux-en-Y gastric bypass. Guy H.E.J. Vijgen, Ruben Schouten, Nicole D. Bouvy, Jan Willem M. Greve. Surgery for Obesity and Related Diseases Vol. 8, Issue 6 ,Pages 803-808

[Last editorial review/modification of this page: 6/7/2013]

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