Revisional versus Primary Bariatric Surgery in a Publicly Funded Program

Caroline E Sheppard, BSc1, Courtney Fulton, MD2, Daniel W Birch, MSc, MD, FRCSC1, Shahzeer Karmali, MD, FRCSC, FACP1, Christopher J de Gara, MB, MS, FRCS, Ed, Eng, C, FACS, FFStd, Ed2. 1University of Alberta, CAMIS, 2University of Alberta

Introduction: Revisional surgery has become an important component of addressing weight regain and complications following primary bariatric surgery. A specialized multidisciplinary revision clinic has been developed to intake patients that require revisional bariatric surgery. The objective of this project will be to analyse the revisional clinic process, review revision and complication rates compared to primary bariatric surgery, and inform future programming and resource allocation in a provincial approach to obesity management and bariatric surgery.

Methods: A retrospective chart review of 529 Bariatric Revision clinic patients was completed from 2010 to 2014.

Results: Patients were 90% female and 47.9±10.1 years of age. Initial BMI was 42.6±11.0 compared to a BMI of 44.2±8.6 before primary bariatric surgery. Patients returned seeking revisional surgery 2 to 17 years after primary surgery. The majority had either a primary vertical banded gastroplasty (VBG) (50%) or a laparoscopic adjustable gastric band (LAGB) (25%); 12% had already undergone some type of revision. Most primary surgeries were performed in Alberta (56%); however, over one third were medical tourists. Patients presented to the revision clinic either because of weight regain (64%), dysphagia (26%), other complications (12%), and/or malnutrition (3%). Bands were removed in 38% of LAGB patients within 3.5 years of insertion. Only 16% of patients followed through the primary clinic required a band removal. Revisional surgery was performed in 15% of patients after 9 months upon entering the revision clinic. Twelve months after surgery patients had a BMI of 33.6±8.3 compared to 33.5±7.7 12 months after primary surgery. The complication rate after primary and revisional surgery was 20% and 36% respectively with wound infection being the primary complaint, and 28% of revisional procedures required additional surgery.

Conclusions: A bariatric revision clinic manages a wide variety of very complex patients, distinct from patients seen in a primary clinic. A minority (20%) of patients were surgical candidates because of exceedingly complex medical, surgical and mental health comorbidities. A significant number of these patients are referred because of lack of resources or are medical tourists with complex medical management. While revisional procedures have an increased complication rate compared to primary bariatric surgery, revisional surgery is integral for significantly decreasing weight regain and addressing both postoperative complications and poor lifestyle recidivism. Therefore, resources are necessary to support revision surgery for this complex group of patients.

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