Revising A Gastric Bypass

The gastric bypass or Roux-en-Y gastric bypass is a combination restrictive and malabsorptive bariatric surgery. It has been the gold standard in metabolic surgery for the best part of a few decades. You could even say it represents the grandfather of modern bariatric surgery. Until the past several years, it was the most widely performed procedure in the United States and remains a commonly used surgery that is especially helpful for patients who have severe or uncontrolled acid reflux as well as those with serious or unchecked type-2 diabetes. During a standard gastric bypass, the surgeon cuts away approximately 85% of the stomach, leaving a small pouch for food about the size of a golf ball. This is the restrictive portion of the procedure.
To reduce the absorption of calories and nutrients, a portion of the small intestine is bypassed and brought up to the stomach pouch, allowing food to enter the small intestine further down the tract. The cutaway portion of the stomach is not removed from the body; instead, it continues to provide gastric juices to the small intestine; however, it does not receive any food.

When a Bypass Fails

The gastric bypass, like other bariatric surgeries, can fail to offer patients the weight loss they expect. This is sometimes (rarely) due to a poorly formed bypass during the initial surgery, and more often, it results from a liberalized diet and a sedentary lifestyle that some patients fall into after months or years of successful weight loss and maintenance. That said, the gastric bypass has a nifty (though uncomfortable) self-limiting fail-safe known as dumping syndrome. If patients eat a large meal or one high in fatty or sugary foods, they tend to experience symptoms akin to hypoglycemia or low blood sugar, which can be pretty miserable, though not life-threatening. This is often enough to keep patients on track and improve their dietary behaviors in the future. That’s not to say, however, that the bypass is foolproof. There is no exact consensus in the literature, but potentially, up to 30% of patients may have issues with their gastric bypass that may require a revision.

If patients are not losing as much weight as they expect, or if their weight loss is stalled and they’re even gaining some weight, the first and most important discussion is with their bariatric surgeon. Before considering any revisional bariatric procedure, one must evaluate their lifestyle habits. Redoubling efforts to eat well according to the bariatric diet and exercise more often can reverse weight gain and get patients back on track. But sometimes that’s not enough.

When it's Time to Revise

More invasive revisional options can be discussed if a concerted effort toward improving diet and exercise has not led to weight loss and getting back on track. Because the rate of gastric bypass failure is relatively low and because of the particulars of the procedure itself, there’s still no consensus on the best revisional procedure. As such, you should speak to your bariatric surgeon about their preferred revision method. With that said, there are options.

Distal Gastric Bypass

The first is a distal gastric bypass, distinct from a standard or traditional proximal gastric bypass. A revision from a proximal to a distal gastric bypass can offer patients significantly improved weight loss and even help them reach the goals and expectations of their original procedure. On the other hand, the distal gastric bypass increases the risk of vitamin and mineral deficiencies and represents a major surgical procedure with all the inherent risks thereof.

Non-Surgical TORe

On the other hand, TORe, or Transoral Outlet Reduction endoscopic, is a non-surgical procedure that targets the opening between the stomach pouch and intestine. The surgeon created this via anastomosis – it is not a natural valve as in the pre-surgical stomach. As such, there is a chance that, over time, the stoma begins to dilate, allowing food to enter the small intestine more rapidly. As you may know, the small intestine is far more sensitive than the stomach and absorbs significantly more nutrition and calories. If the stomach empties quickly, known as rapid gastric emptying, there is a significant likelihood of weight regain. The TORe procedure aims to tighten the stomal opening using sutures to fold tissue and reduce its diameter. TORe and other endoscopic options like the ROSE procedure may help patients get back to losing a significant amount of weight, and the likelihood of additional stoma dilation is significantly reduced.

Insurance Coverage for a Bypass Revision

Because there are no defined criteria for a gastric bypass revision, the decision is up to the patient and their doctor. Insurance coverage for revisions is approved on a case-by-case basis. You should first work with your surgeon to find a non-procedural solution, often in the form of improved diet and exercise and possibly even GLP-1 agonist medication injections, to ensure that you have exhausted every noninvasive option before turning to a procedure. With that said, for many patients, especially those with relatively more weight to lose, a surgical or endoscopic procedure is the gold standard for getting back on track. Most importantly, catching weight regain in its earlier stages allows for more options. Patients should be comfortable speaking to their bariatric surgeon about any struggles they may be having, including weight regain.

There’s no shame in regaining weight; some people do after their bariatric procedure. This is not a failure but rather an opportunity to get back on your path toward your goals.