News - 19/02/2022
QUESTION: "Hello Doctor, I underwent a bypass in 2015, and I lost 50 Kg the following year; since I regained 20 Kg, can we do a review of the bypass?"
REVISION SURGERY: we call "revision surgery" any surgery secondary to a bariatric procedure that has led to a complication or an insufficient result.
SEVERAL SITUATIONS CAN OCCUR:
1) Gastroesophageal reflux is a complication specific to the surgery itself; normally the liquid secreted and contained by the stomach is very acidic (in order, among other things, to destroy microbes swallowed with food) and this acidic liquid must not flow back upwards (towards the mouth) through the esophagus, its acidity would then lead to serious burns and repeated lung infections.
-The diagnosis is simple: painful sensations of burning behind the chest from bottom to top and cough by irritation of the throat, especially on waking.
-TOGD and pH-metry confirm the diagnosis.
-An intervention is necessary, because the antacid treatment is ineffective: ablation of the Gastric Band or transformation of the SLEEVE into BY-PASS (the stomach then being short-circuited, there can no longer be any acidic liquid).
2) Food and vitamin deficiencies; after any malabsorptive procedure (that is to say which decreases or eliminates the absorption of food and VITAMINS) whether it is a biliopancreatic diversion (most often) but also a By-pass (much more rarely) a few rare patients lose too much weight despite a well-conducted nutritionist follow-up, and this, probably due to a vitamin absorption disorder.
-The diagnosis is easy: uncontrolled weight loss, muscle wasting...
-The treatment is always surgical, but technically difficult.
3) INSUFFICIENT WEIGHT LOSS OR WEIGHT GAIN AFTER CORRECT WEIGHT LOSS REMAINS THE MOST FREQUENT SITUATION, very frequently after fitting a Gastric band (a practically abandoned procedure), rarely after a SLEEVE and a normal stomach, exceptionally after a BY-PASS.
REPLY : "NO, you should not operate again with a BMI of 36 before having tried a nutritionist follow-up for 6 months UNDER THE MONITORING OF A NUTRITIONIST".
⇒ A MAJOR CAUSE: THE LACK OF NUTRITIONAL MONITORING. The Gastric Band and SLEEVE GASTRECTOMY are restrictive procedures, it means that they aim to reduce the food quantities, but not their absorption by the intestine, they can therefore only lead to a satisfactory result if your diet is monitored regularly, at best by a dietician.
Personally, I ask my patients to write in a dedicated notebook 15 days of their diet every 2 or 3 months and have it validated by their dietician or me.
⇒ IF, AND ONLY IF, the diet is correct, it is then necessary to consider a REVISION** surgery : Gastric Band removal, then SLEEVE, or BY-PASS depending on the degree of obesity and especially comorbidities (mainly diabetes).
** REVISION of the SLEEVE or more often BY-PASS in case of failure of this one after having practiced a simple gastro-scan which makes it possible to measure the volume of the remaining stomach (remember that a normal stomach contains 1, 5 liters and that after a well-made SLEEVE its capacity should only be ¼ liter).
⇒ FRENCH HEALTH INSURANCE currently requires a complete file before authorizing revision surgery. It is necessary to redo practically all your file with the same examinations as those carried out before the first procedure and in particular 6 months of follow-up by a nutritionist, even one year, are REQUIRED. Follow-up, documented by written evidence: date of consultations by a specialist (dietician, nutritionist or endocrinologist) prescriptions that must mention one of these specialties.
TO CONCLUDE :
Revision surgery should remain infrequent, it generally reflects failure (gastric banding should only be performed for very specific reasons). The SLEEVE must be of sufficient size and checked by an X-ray (gastro-scan), the BY-PASS well measured. Despite all these precautions, follow-up is essential for many years.
This follow-up is not so restrictive and much less than that imposed by other diseases (diabetes, high blood pressure, etc.) and it is difficult to understand why 4 annual consultations (now by videoconference) are so complicated to obtain!
© Author: Dr. Jean-Pierre ANFROY - Surgeon