Revising a Gastric Sleeve

The gastric sleeve has become the most popular bariatric surgery in the United States due to its simplicity and exceptional excess body weight loss potential. However, this procedure wasn’t always a standalone. In the early days, the gastric sleeve was the first part of a duodenal switch that was used mainly for people with extreme BMIs. The gastric sleeve cuts away approximately 75 to 80% of the existing stomach pouch along the greater curvature, leaving a banana or sleeve-shaped stomach behind. The excised portion of the stomach is removed from the abdomen, and with it goes the fundus, primarily responsible for the secretion of a hunger hormone known as ghrelin. By eliminating this ghrelin production center, patients feel fewer hunger pangs and can lose a significant amount of excess body weight loss – almost as much as a gastric bypass.

The Role of a Hiatal Hernia in Post-Sleeve Complications

A somewhat common and debilitating concern following a gastric sleeve is new or worsened gastric reflux. Traditionally, this has occurred in about 20% of gastric sleeve patients, and there is no sure way to know who is at risk. However, we do know that the presence of a hiatal hernia, something that many bariatric patients have developed due to the intra-abdominal pressure associated with obesity, increases the risk of reflux. Thus, repairing a hiatal hernia dramatically reduces the risk of gastroesophageal reflux after a sleeve, making the surgery even more successful.

Gastric Sleeve Pouch Dilation

The newly formed gastric sleeve is a high-pressure tube with the lower esophageal sphincter acting as the valve between it and the esophagus and the stomal valve, helping prevent food from entering the small intestine too quickly. As a result of this high-pressure system, there is the possibility of dilation or stretching of the pouch due to continuous overeating. Remember, the gastric sleeve does not have the inherent self-limiting factor that gastric bypass does – dumping syndrome. While it is still uncomfortable to overeat with the gastric sleeve, smaller but consistent episodes of overeating can make the stomach adapt to a new, larger reality. Of course, there is also the possibility that the initial gastric sleeve procedure did not remove as much tissue as we know is optimal. As a result of this dilation or a lack of restriction, some patients may begin to gain weight after their procedure. For these patients, there are usually several options for correction.

1. Re-sleeve, where more tissue is cut away along the greater curvature, and the sleeve is made significantly smaller to once again restrict the amount of food that can be eaten and ultimately restart the weight loss process.
2. The sleeve is also amenable to conversion to a gastric bypass. This requires making the existing sleeve smaller and bringing up a loop of the intestine to bypass.
3. Since the gastric sleeve was traditionally the first part of a duodenal switch, it is relatively straightforward to perform the second malabsorptive component of the DS, which involves bypassing some of the intestine.
4. Last but certainly not least is the possibility of a SASI, known as a Single-Anastomosis Sleeve Ileal Bypass. This procedure reduces the pressure within the gastric sleeve by bringing up a loop of the intestine and attaching it to the anastomosis suture line. This effectively eliminates acid reflux in patients experiencing it and helps them lose additional weight due to malabsorption.

A Ghrelin Comeback

Before entertaining any of the above revisions, surgeons often look for signs of overeating. Patients are frequently asked to journal their eating habits and feelings about food. This can direct the next steps to help with continued weight loss. Eventually, after approximately 1 1/2 to two years, the small intestine may begin producing ghrelin to compensate for the absence of the fundus of the stomach, removed during the primary bariatric procedure. This ghrelin secretion, albeit much less than the original stomach production, can make patients hungrier, and some begin to eat more despite the discomfort and consequences associated with doing so. Redoubled efforts toward proper diet and exercise for these patients can get them back on track since the original sleeve is still intact.

How Do I Know When My Sleeve Should Be Revised?

Following up with your bariatric team is the most critical first step when you are concerned about your gastric sleeve. Speaking to the dietitian or surgeon is essential to getting ahead of the weight regain before it becomes overwhelming. Some patients are embarrassed that they are regaining weight, considering it a failure. However, this cannot be further from the truth. Some weight fluctuations are expected, but severe increases in weight or yoyo weight gain and loss should not be taken lightly. Speaking to your bariatric practice early on can help you find the most appropriate next step, which usually involves evaluating diet and exercise habits. If it’s determined that diet and exercise are not to blame and the weight regain is occurring despite your best efforts, we can speak to your insurance company to get coverage for a revisional procedure. Again, each revisional procedure mentioned above has its risks and benefits. As such, a discussion with your bariatric surgeon is the best way to understand your options. It’s essential to choose a practice that is highly experienced in bariatric revisions, as there can be additional complications compared to the primary bariatric procedure, not least of which is the presence of scar tissue that can make the surgery more complex. However, most patients succeed after their revisional or conversion procedure after a gastric sleeve. Many hit their goal weight and maintain it over the long term. As with the primary bariatric procedure, your focus and dedication to a new and improved lifestyle are the keys to long-term success.