Which Bariatric Surgery Needs Most Revisions Over the Decades?

Over the course of 20 years, just over one-quarter of bariatric surgery patients underwent revisional procedures, researchers reported.

In a follow-up analysis of participants from the Swedish Obese Subjects (SOS) study, 27.8% of adult patients underwent a first-time revisional surgery — accounting for 559 patients out of 2,010 — Stephan Hjorth, PhD, of the University of Gothenburg, and colleagues wrote in JAMA Surgery.

Among these revisional surgeries, conversions to other bariatric procedures were the most common, making up nearly 18% of these surgeries. This was followed by around 6% of revisions accounting for corrective surgeries, while 4.5% were reversals back to normal gastrointestinal anatomy.

The reasons for revisional surgery included weight-associated indications; band- or staple-related technical complications; and surgical-associated complications including infection, stoma stenosis, stoma dilatation, pouch enlargement, reflux, and nausea.

Between the three surgeries assessed — banding, vertical banded gastroplasty (VBG), and gastric bypass (GBP) — people who underwent banding were the most likely to undergo any type of revisional surgery over the maximum 26-year follow-up period. Nearly 41% of patients who underwent banding had a revisional surgery.

Revisions were less common for vertical banded gastroplasty patients, occurring in around 28% of patients. Revisions were the least common among those who underwent gastric bypass, with only 7.5% of these patients undergoing revisions.

As for reversal surgeries, those with banding were five times more likely to have a surgery reversal compared with those with VBG (40.7% vs 7.5%; HR 5.19, 95% CI 3.43-7.87, P<0.001). Banding and VBG patients were most likely to undergo a reversal or a conversion to gastric bypass.

However, when it came specifically to corrective surgeries — which mostly occurred within the first 10 years postoperatively — these generally had similar rates of incidence between all three types of surgeries, ranging from 5.3% of those with VBG to 7.1% of GBP patients.

“The greater weight loss after GBP is the likely main reason for a lower request for conversions in this subgroup compared with the subgroups that undergo banding and VBG,” wrote the researchers.

When broken down by surgery type, the most common reason for a revisional surgery among those who had banding was band-associated problems, such as migration stenosis or slippage. Among banding patients, nausea and weight-related indications were also common reasons for revision.

As for VBG patients, the most common indication for revisional surgery was staple-related disruptions, accounting for 10% of these patients. Nausea due to stenosis and collar migration were also common indications for revision. The most common indications for revisional surgery for gastric bypass patients were reflux-associated and esophagus-associated complications.

“The dominant reason for corrective revisional surgery was bile reflux (including esophagitis), which occurred only in patients with loop technique GBP,” the researchers noted, adding how “this demonstrates the superiority of the Roux-en-Y technique with regard to the need for secondary interventions.”

In an accompanying commentary, Ricardo Cohen, MD, of Oswaldo Cruz German Hospital in Brazil, praised the study, writing that “although the SOS study started in the 1990s and operative techniques have evolved, it brings answers about bariatric revisional surgery and raises thoughts regarding choosing the best index bariatric procedure.”

Cohen also pointed out that although the small percentage of gastric bypass patients included in the cohort was a limitation, it’s still apparent that this surgery accounted for fewer revisionary surgeries. “Among more than 200 Roux-en-Y gastric bypass procedures, only five (2.3%) required any reoperation,” he said.

“Revisional surgery carries a higher complication rate than the primary procedure, but if needed, it should not be denied,” Cohen added, also noting the growing number of reported revisions with the recently popular sleeve gastrectomy. Ultimately, he said, “maybe a wiser movement is to start with the right choice and curb the need for reoperations.”