Is a Gastric sleeve revision to gastric bypass my best option?

Surgeon Response to "Is a Gastric Sleeve Revision to Gastric Bypass My Best Option?"

by: John Rabkin, M.D., Pacific Laparoscopy

Steve,

Weight regain after Verticle Sleeve Gastrectomy (VSG) is unfortunately quite common. The VSG is a purely 'restrictive' weight loss surgical procedure (WLS) without any 'malabsorptive' component. Consequently, when the restriction lessens over time, it takes more food to produce the sense of satiety that makes you 'feel full' and stop eating: over time this required quantity of food and calories may exceed a patient's ability to burn off those consumed calories and the end result is weight regain. Longer term outcome studies show weight regain of up to 50% by 5 years post procedure in VSG patients.

The VSG as originally conceived was the initial procedure (first part) of a 'staged' (two part) Duodenal Switch (DS.) It wasn't intended originally to be a 'stand alone' WLS procedure. As originally performed, super morbidly obese patients undergoing the DS would initially have their stomach sleeved and then, after substantial weight loss from the sleeved stomach restricting their caloric intake, they would return months to years later to undergo the completion (second part) of the DS procedure which created calorie malabsorption of primarily consumed fat calories, ensuring long-term weight loss maintenance.

When someone faces weight regain after the VSG despite their best attempts at limiting their caloric intake and adhering to an exercise regimen, revisional WLS is an appropriate consideration. Unfortunately, revisional WLS is much more complicated (and complication prone) than 'de novo' WLS procedures. Alternative approaches to the revisional WLS include endoscopic shrinking of the sleeve and VBLOC gastric stimulator placement. My experience with patients who have tried these approaches has been less than satisfactory with inadequate weight loss achieved. (Full disclosure: I don't perform these procedures and may be seeing a select population of patients who haven't done well with these approaches.)

Options for revisional WLS include 're-sleeving' the VSG sleeve, placing an adjustable gastric band ("LapBand") over the sleeve, converting the VSG to a Roux-en-Y Gastric Bypass (RNY) and/or COMPLETING the second stage of the 'Staged' Duodenal Switch (or in other words, changing the 'failed' VSG to a DS.) Although all of these options may be appropriate for the right situation and patient, I routinely recommend that patients with significant weight regain after a VSG simply complete the DS as originally intended!

In all cases, patients seeking revisional WLS need to review their options with an experienced bariatric surgeon who routinely performs revisional WLS. This may require a patient to change from their original bariatric surgeon to another, more experienced practitioner. 'Second go arounds' will be more difficult for the prospective patient (and bariatric surgeon!) but can be highly rewarding with the subsequent weight loss achieved even exceeding the original WLS procedure with an excellent accompanying quality of life. However, choose carefully: what you don't want to face in the future is 'third strike, you're out!.'

John Rabkin, M.D.
Pacific Laparoscopy

(click here for Dr. Rabkin's full bio & contact info)

DISCLAIMER: This educational advice is based on the depth of your question and the details provided. The above should never replace the advice of your local physicians as they have the ability to evaluate you in person.

Related Pages:

• Gastric Sleeve Diet - Pre-op, Post-op, & Long-term
• Life After Bariatric Surgery - All You Need to Know