Debate: Revisional Bariatric Surgery Should Never Be Performed on a Patient Who Gains Weight: Pro

Educational Objectives

The goal of this program is to improve the surgical care of patients with obesity. After hearing and assimilating this program, the clinician will be better able to:

1. Weigh the arguments for and against revisional bariatric surgery.

Summary

Pro: Dr. Grover

Exceptions to rule: revision of anatomic causes of weight regain (eg, gastrogastric fistula and creation of large gastric pouch at initial operation may fail to reduce levels of gut hormones [eg, ghrelin], excessively wide gastrojejunal anastomosis may not achieve adequate restriction); revision in patients who underwent “inadequate” initial operation (eg, adjustable gastric band)

Reasons for failure of weight loss: poor operative technique — large gastric pouch; large gastric sleeve; complications of procedure — gastrogastric fistula; poor choice of procedure; postoperative lifestyle choices — poor eating habits; lack of exercise

Options for conversion: goals — increasing malabsorption; increasing restriction; patients with gastric bypass — endoluminal or laparoscopic reduction of size of gastric pouch or width of stoma; lengthening of biliopancreatic or Roux-en-Y limb; application of gastric band over bypass; conversion of bypass to duodenal switch; patients with sleeve gastrectomy — conversion to gastric bypass or biliopancreatic diversion (BPD); “resleeving” of sleeve gastrectomy; band over sleeve; patients with adjustable gastric band — any other bariatric operation; patients with BPD — altering common channel and resleeving; patients with vertical banded gastroplasty (VBG) — any other major procedure

Results of revisional surgery in patient with weight regain: majority of revisions performed 2 to 3 yr after index operation; majority of studies limit follow-up to 1 yr; large majority (if not all) found significantly higher rates of complications compared with primary surgery; Tran et al (2016) — systematic review of conversion of gastric bypass procedures found successful weight loss at >1 yr; incidence of major complications (eg, leak, pulmonary embolism, death) high; conversion to distal bypass resulted in surgical revision in 20% of patients (because of protein-energy malnutrition); distal bypass resulted in sustained reduction of excess weight (even after 5-10 yr); band over bypass resulted in only 14% reduction in excess weight at 3-yr follow-up; endoluminal procedures yielded no reduction in excess weight at >1 yr follow-up; speaker considers average rates of complications (20%-30%) and protein-energy malnutrition (≤31%) unacceptable; McKenna et al (2014) — revisional surgery did not result in significant weight loss but did resolve comorbidities; conversion of VBG to gastric bypass or revision of bypass associated with high rates of complications; comorbidities resolved (follow-up 12-18 mo); authors concluded that revision of VGB to gastric bypass yielded less weight loss than expected and high rates of complications (but good resolution of comorbidities)

Conclusions: surgery most successful treatment of obesity, but not all patients lose weight; patients who regain weight typically fail to make appropriate changes in lifestyle (eg, exercise); revisional surgery that does not address patient’s failure to change lifestyle contributes to high rates of complications and low rates of long-term success

Con: Dr. Luthra

Challenges of revisional bariatric surgery: increased complexity and higher rates of complications; possibility of less favorable results than for initial operation; revisions to bariatric operations similar to other revisional operations (eg, revascularization for patients with coronary or peripheral arterial disease); revisional bariatric surgery may cause harm, but doing nothing also may cause harm

Management of obesity: patients at risk require strategies for prevention; those with end-stage disease require palliative strategies; those with established disease require intervention based on risk and stage; obesity considered chronic disease (any intervention may result in only partial response or recurrence); providers should offer adjuncts to, and escalation of, therapy

Treatment of established disease: should not be denied because patient relapses; ≈33% of initial weight loss regained at 10 yr (compares favorably with primary and secondary rates of patency for vascular grafts)

Revisional bariatric surgery: leads to improved loss of excess weight and reduction of comorbidities; ethics of health care dictate principles of medical care; duty to provide treatment viewed as stronger when medical condition considered disease (obesity previously stigmatized); informed patient final arbiter in weighing benefits and harms of treatment; physicians who withhold available options deny right of autonomy to patients; stigma of obesity propagated by refusal to treat recurrent or persistent disease; revisional bariatric surgery type of palliative therapy for treatable condition; allocation of resources guides denial of revisional surgery

Readings

Filho AJ et al: Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass. JSLS 2006 Jul-Sep; 10(3): 326–331; Herman KM et al: Keeping the weight off: physical activity, sitting time, and weight loss maintenance in bariatric surgery patients 2 to 16 years postsurgery. Obes Surg 2014 Jul;24(7):1064-72; McKenna D et al: Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss. Surg Obes Relat Dis 2014 Jul-Aug;10(4):654-9; Tran DD et al: Revision of Roux-en-Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg 2016 Jul;26(7):1627-1634.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Grover and Dr. Luthra were recorded at the Bariatric Education Days: Evolving Treatment Across Health Systems, presented by the University of Minnesota Medical School and held May 25-26, 2016, in Minneapolis, MN. For information on other CME activities from the University of Minnesota Medical School, please visit cme.ahc.umn.edu. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS631503

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.