Revisional Bariatric Surgery: Perioperative Morbidity is Determined by the Type of Procedure

Kishore Malireddy, MD, Ryan Phillips, BS, Evon Zoog, BS, Timothy Kuwada, MD, Keith Gersin, MD, Dimitrios Stefanidis, MD, PhD

Carolinas Healthcare System, CMC-Mercy

Introduction: Revisional bariatric procedures are on the rise and are expected to continue increasing given the high number of primary procedures being performed in the US. The higher complexity of these procedures has been reported to lead to increased risk of complications compared with primary bariatric procedures. The objective of our study was to review the indications and perioperative risk profile of revisional bariatric surgery compared with primary bariatric procedures.

Methods: A prospectively maintained database of all patients undergoing bariatric surgery by three fellowship trained bariatric surgeons between June 2005 and June 2012 at a center of excellence was reviewed. Patients who underwent revisional bariatric procedures were identified and divided into four categories: band to bypass, band to sleeve gastrectomy, bypass revision, and fundoplication to bypass. Patient age, baseline BMI, type of initial and revisional operation, number of prior gastric surgeries at time of operation, indications for revision, postoperative morbidity and mortality, length of stay, 30-day readmissions, reoperations, and leaks were recorded. These outcomes were compared between revisional and primary procedures using Mann Whitney or Chi-square tests. Under morbidity we included readmissions or postoperative ER visits, wound infections, pulmonary embolism, urinary tract infections and other less frequent complications.

Results: Out of 1519 patients undergoing bariatric surgery 74 (4.9 %) had revisional procedures during the study period. Indications for revisions included inadequate weight loss in 47 (63.5 %) patients, failed fundoplications with recurrent GERD in 25 (33.8 %) patients, recalcitrant anastomotic ulcers in one patient, and excess weight loss in one patient. Revisional procedures were associated with higher rates of readmissions and overall morbidity but no differences in leak rates and mortality compared with primary procedures. Band revisions had similar LOS and did not require reoperations compared with the respective primary procedures but patients after bypass revision or fundoplication to bypass revision had longer LOS, higher leak rate, and 20% required repeat surgery(see table).

Conclusions: In experienced hands, revisional bariatric procedures can be accomplished with excellent perioperative outcomes that are similar to primary procedures. As the complexity of the revisional procedure and number of prior surgeries increases, however, so does the perioperative morbidity; fundoplication revisions to gastric bypass represent the highest risk group.

Outcome comparison between primary and revisional bariatric procedures

Procedure# patientsAgeBMI# prior gastric operationsLOSMorbidityMortalityLeaks30-day ReadmissionsReoperations
Primary RY Gastric Bypass118142.344.702.110%‡0.1%0.3%8%‡1.1%
Primary Sleeve Gastrectomy27344.143.902.18%‡0%0%4%‡0.3%
Band to Bypass2247.740.01*224%*0%0%14%*0%
Band to Sleeve144239.71*228%*0%0%14%*0%
Bypass Revision1352*†42.51.3*†3.2*†15%*0%0%15%*15%*†
Fundoplication to Bypass2555*†34*†1.6*†7*†40%*0%4%*†40%*†20%*†

*= p<0.05 compared with primary bypass or sleeve gastrectomy
†= p<0.05 compared with band revisions
‡= incidence based on a random sample of 100 patients

Session: Podium Presentation

Program Number: S013

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