Revisional bariatric surgery : more than a moral obligation

Abstract: Growing awareness of biological, genetic, environmental, and behavioural factors contributed to the recognition of obesity as a chronic disease. Nowadays, obesity and its medical/surgical treatment is widely acknowledgedin the medical curriculum. Bariatric surgery has long been shown to provide superior induction and maintenance of weight loss, together with improvement or resolution of obesity-related diseases. The role of revisional bariatric surgery for treatment of procedure-related complications is accepted. However, its role as second-line treatment of patients with primary or secondary non-response is still a matter of debate. This prompted Dr Henry Buchwald in 2015 to publish his article “Revisional Metabolic/Bariatric Surgery: A Moral Obligation”. Studies I and II in this doctoral thesis covered issues that fuel the ongoing controversy, namely effects and risks of revisional surgery. Conversion to gastric bypass is the most common revisional procedure in Sweden. In Studies I and II, we found revisional gastric bypass to give inferior weight loss with a higher risk for perioperative complications compared to primary gastric bypass. However, the beneficial effects on obesity-related disease were similar (Papers I and II). In Study III, the theoretical need for revisional bariatric surgery in patients with primary or secondary weight non-response was evaluated. When applying four different indication criteria, more than 13% of patients met the criteria for second-line treatment, with a significant higher probability after sleeve gastrectomy compared to gastric bypass (Paper III). To gain a clearer picture, a systematic review of the literature on revisional bariatric surgery after sleeve gastrectomy was inevitable. However, an evidence-based treatment strategy for patients with primary or secondary weight non-response could not be deduced from the current literature (Paper IV).