Two Ways We Revise a Gastric Sleeve
Which revisional procedure to perform depends on the individual scenario. But before proceeding with how to treat recidivism and/or reflux, one word of caution. These surgeries are technically more demanding, and only surgeons with extensive bariatric experience should be performing these surgeries.
I am proud to note that in the last 14 years, we have not had a staple line leak from these surgeries, encompassing approximately 30% of my practice.
If the patient did well initially but has regained weight, and the sleeve is dilated, then the option to re-sleeve (redo the sleeve as if it were the first time) is available. In this case, the patient usually regains weight after several successful years of weight loss, and when studied, the stomach has grown and dilated (thus the weight gain). Most patients who are happy with their sleeves will choose this option.
If the patient hasn’t had success with weight loss and the sleeve is dilated (or not), a gastric bypass should be performed.
The patient develops reflux and weight regain after years of successful weight loss. In this case, the patient develops reflux after the weight regain, and the sleeve is dilated. Here, we can re-sleeve or perform a conversion to a gastric bypass. If a hiatal hernia is present, it must be repaired also.
Reflux after a sleeve is fairly common, occurring in 20-25% of cases. In the scenario that patients develop severe reflux soon after the surgery, with or without weight loss, and with or without a dilated sleeve, a bypass should be performed.
If the patient has regained weight today, we also have the option of GLP-1 medications (Wegovy) to try to reboot weight loss or jumpstart a patient who has not lost enough weight with the surgery. Again, one can use these meds intermittently as needed, especially if the patient has insufficient weight loss or weight regain and the sleeve is not dilated. If the patient wants to use these meds solely, one must remember this is a long-term proposal because several studies have shown weight regain once the medications are stopped.
Which Bypass to Perform as a Revisional Surgery
The classical Roux-en-Y Gastric Bypass (RGB) is the most common operation. It works very well for reflux and weight loss. Thankfully, the incidence of side effects is low, but include malabsorption, internal hernias causing intestinal obstruction, ulcers at the junction between the small bowel and stomach, and dumping.
Recently, I’ve been performing a procedure called SASI (Single Anastomosis Sleeve Ileostomy). I call this a “gentler bypass”. It entails connecting a simple loop of small bowel to the bottom portion of the sleeve but keeping the continuity of the stomach intact, unlike the Roux-en-Y bypass where the stomach is completely transected. If the sleeve is dilated, the upper portion of the sleeve can be redone. This allows for weight to occur because of the sleeve restriction and through the connection of the small bowel (loop bypass). But because the stomach is intact, the incidence of malabsorption is less (as only about 60-70% of the nutrients go through the bypassed area, vs. 100% in the RGB, and because it creates a low-pressure zone in the sleeve, it works very well for reflux. Technically, it’s easier than RGB, and the incidence of complications, including leaks, is less because there are fewer connections to perform.