1. It’s not your fault that the gastric bypass failed. I know that everybody tends to blame themselves, but the science and the evidence support a very different conclusion. The truth is that the problem is a result of the intersection between a person’s genetics and the obesogenic environment. That’s it. Huge changes in everything we grow and prepare and consume, combined with many other factors in the environment (think medications, antibiotics, chemicals, to name a few), have hijacked our genes and cause more weight gain and fat storage. That doesn’t mean that we’re totally off the hook from fighting it. In fact, I would argue that recognizing the enemy we face means we have to fight it 10 times as hard. But don’t blame yourself in the process of fighting to get healthier. It’s futile, and it doesn’t help.
2. There very likely is a successful revision option. You may have been told there was no way to revise the procedure in the past. And while it’s true that bariatric surgeons struggled in past decades to come up with a reliable procedure that both worked well and was minimally invasive with few side effects, today that is precisely the reality. In recent years, excellent results are routinely obtained at top centers with minimally invasive revision.
3. The best results come from personalizing the revision procedure. No two people are the same, and there is definitely not a one-size-fits-all revision procedure after a failed gastric bypass. The best results take into account a person’s current weight, BMI, weight loss history, health conditions like type two diabetes, and individual anatomy during surgery.
4. There is a big advantage to laparoscopic. This might seem totally obvious, but I find that people underestimate why we surgeons so strongly favor laparoscopic surgery. The very small cuts using video technology (and whether this involves a robot or advanced laparoscopic instruments makes zero difference) means the person on the receiving end does not have a large incision. It means a lot less pain and a lot less recovery time. But possibly even more importantly, the procedure creates dramatically less scar tissue — specifically the kind of internal scar tissue we call adhesions. With open surgery and all the manipulation of the intestines, adhesions often form everywhere, and this makes future surgery very difficult — and sometimes impossible. The adhesions can also cause problems of their own, like bowel obstructions.
5. It’s all chemistry. Weight regulation has a lot to do with the body’s own internal chemical control mechanisms, sort of like a home’s thermostat. We now know that the body operates with a setpoint for body weight, much like our home has a setpoint for the temperature. Losing any meaningful weight without dialing down the setpoint is almost impossible. And the only way to turn down that setpoint is to change the chemistry, or the hormones that regulate body weight, with surgery. Most of those hormones are in the intestine and stomach, and they are changed with the revision surgery that directly affects the tissues, which dials down the thermostat to a lower, healthier, body weight setpoint.
6. Line up all of the positive factors. This revision procedure is a second chance. So this time around, get everything pointing in the right direction. Plan to devote an even more serious effort to the pre-and post-operative program, the recovery process, the diet, the exercise, the mental, spiritual, and physical aspects. In some cases, people had factors working against them with the original surgery. This time, do everything in your power to line up all factors in your favor.
7. Exercise more than you ever imagined. No one ever tells us as children that we’ve just joined a planet and a society in which everything we are being fed is going to cause obesity. Or that to fight it, you likely need to devote two full hours of every single day to exercise — for the rest of your life. But that’s a pretty reasonable prescription given the current environment in which we find ourselves. I would love to sugarcoat it and say that going to the gym three days a week and taking the dog for a walk around the block every other day, on top of your regular 10,000 steps at work, was enough. But the truth is, it isn’t. You need seven days a week of exercise, building up to way more minutes of actual exercise than you ever thought would be necessary. Getting there is not easy. But it is necessary.
8. Find the center and the surgeon with experience in revisions. There are many wonderful, young, talented surgeons and excellent recently formed programs. But this is a specialized aspect of surgery, and a few gray hairs plus a couple of decades in the field make a world of difference when it comes to revision procedures.
9. Striking a balance between minimally invasive and maximally effective is the best way to go. A laparoscopic procedure that changes the bypass to bring it up to the best modern standards, with a longer biliopancreatic limb as a key feature, usually brings the best results with the fewest potential side effects or complications.
10. If you’re confused by the nomenclature of revisions on google or websites from different centers, you’re not alone. Duodenal switch, biliopancreatic diversion, and acronyms like SADI all point to a category of procedures that work well to change the body chemistry toward weight loss. Some of the lessons learned from these procedures are employed in the most effective, but simpler, revision procedures for failed gastric bypass. Distalization, limb-lengthening, or conversion to long limb bypass describe revising the past procedure to make the limbs of the “Y” of the Roux en Y gastric bypass, longer. This causes more favorable change to the body chemistry and jumpstarts the weight loss.
11. Efforts to simply tighten the gastric pouch have proven mostly unsatisfactory. They’re too often unsuccessful and usually expensive, since insurance usually does not cover it. So choose this option with caution, be prepared to pay a lot out of pocket, and keep expectations lower than you might like. It might seem like restricting the calories should work to induce weight loss, but this approach does not affect the underlying body chemistry, and restrictive approaches have always resulted in less success than we had hoped.
12. A conversion to duodenal switch sounds attractive on the surface but is notorious for resulting in leaks and other serious complications. So, this option also deserves a good deal of caution and not many centers still favor this idea. In a few centers, this process of converting RYGB to DS is done in stages to minimize those complications. We don’t view this one as one of our top options, given better alternatives in recent times.
13. The field is always evolving. A number of well-conducted studies were published in 2019 and 2020 from centers across the globe showing strong results and minimal invasiveness, appearing to offer the Goldilocks combination of safe, simple, and most effective. The procedure, under names like distalization or limb-lengthening, is normally performed with laparoscopy, hence minimally invasive, and has few complications. It involves lengthening the limbs of the gastric bypass with special attention to the biliopancreatic limb or “BP limb” believed to be critically important in resetting the hormones needed to lose weight.
14. Potentially any revision procedure might result in loose bowel movements and more micronutrient malabsorption because the “bypass” is made somewhat more aggressive. With experience, our center and others like it have optimized the revision and limb lengths, personalized to each individual, so nutritional side effects are minimized, while weight loss – and health improvement – is maximized.
15. Most people, and most doctors, significantly underestimate the health toll of obesity, and most people overestimate the risk and inconvenience of revising the prior gastric bypass. In the overwhelming majority of cases, the risks of ongoing obesity are extremely significant over time, leading to miserable health problems and a shorter life. Revision surgery is usually very straightforward, minimally invasive, and provides major health improvement and low side effects.
16. Stick with the vitamins for the long term. You should have already been taking regular vitamins after RYGB surgery. And your doctor should be checking vitamin levels with routine blood tests. After a revision procedure, it is important to stay diligent with your daily vitamins and the regular blood tests to make sure they are staying in the normal range.
17. Triglycerides usually go way down after revision with distalization. Something about the chemistry again; the change in hormones from revision of the gastric bypass usually has a profound effect lowering the serum triglycerides, one of the main risk factors for arterial plaques (triglycerides are a chief component of what people commonly refer to when they talk about lipids and cholesterol.). Along with lowered triglycerides, people enjoy significantly lower risk of heart attack, stroke and other cardiovascular disease.
18. Type 2 diabetes needs to be put into complete remission, not just managed with medications. If you or your loved one are on the fence about revising the gastric bypass, consider the dramatic difference in health outcome for people who totally reverse their diabetes with surgery, compared to those who keep living with their type 2 diabetes, taking medications to manage the blood sugar. Large trials show the “manage the diabetes with medications” approach results in double the chance of heart attack and death. There is a strong possibility that your type 2 diabetes could be cured or put into remission with surgery, so don’t settle for a treat-the-number approach instead of the treat-the-person plan you deserve.
19. Take two weeks off for the revision procedure, give or take. Often, people with an office job and no desire to miss work can go back in 1 week, but I normally advise to plan 2 weeks off. And if you have a more physical job and long shifts, it’s best to plan 3 weeks off. It’s a good time to establish that new 7-days-a-week exercise routine before you’re back to the grind of work.
20. Try not to listen to people who disparage bariatric surgery or the people who had bariatric surgery that “didn’t work.” Obesity is an incredibly difficult to treat environmental disease, and the best treatment by far is surgery. Just like cancer surgery or hip surgery, it offers amazing health improvement but sometimes needs to be repeated or revised.
21. Some day there will be a drug. Right now, we are at the dawn of a much better understanding of the setpoint, obesity, and the factors that contribute to it. Today, there is no pill, no special diet, no exotic herb, no counseling method, and unfortunately no exercise regimen that changes the physiologic setpoint. Only surgery does this. Because surgery physically changes the tissues where these hormones originate. One day, we will have treatments that mimic the effects of surgery, cause a dramatic lowering of body weight, reversal of type 2 diabetes, resolution of sleep apnea and all the incredibly helpful things bariatric surgery does. Some day might be a decade or two from now. In the meantime, if you have questions about bariatric surgery, we’re here to answer them.
