CONTINUING EDUCATION

Perioperative Nursing Careof the Patient UndergoingBariatric Revision Surgery

JANICE A. NEIL, PhD, RN 3.5

www.aorn.org/CE

Continuing Education Contact Hoursindicates that continuing education contact hours are

available for this activity. Earn the contact hours by reading

this article, reviewing the purpose/goal and objectives, and

completing the online Examination and Learner Evaluation

at http://www.aorn.org/CE. A score of 70% correct on the

examination is required for credit. Participants receive feed-

back on incorrect answers. Each applicant who successfully

completes this program can immediately print a certificate of

completion.

Event: #13505

Session: #0001

Fee: Members $21, Nonmembers $42

The contact hours for this article expire February 29, 2016.

Purpose/GoalThe purpose of this activity is to enable the learner to more

effectively care for patients undergoing bariatric revision

surgery.

Objectives

1. Describe types of bariatric surgery.

2. Explain why people undergo bariatric revision surgery.

3. Discuss complications that patients undergoing bariatric

revision surgery may experience.

4. Identify safety precautions that perioperative nurses

should institute for patients undergoing bariatric revision

surgery.

210 j AORN Journal � February 2013 Vol 97 No 2

AccreditationAORN is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Center’s

Commission on Accreditation.

ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-

cation, as well as other continuing education requirements.

AORN is provider-approved by the California Board of

Registered Nursing, Provider Number CEP 13019. Check with

your state board of nursing for acceptance of this activity for

relicensure.

Conflict of Interest DisclosuresDr Neil has no declared affiliation that could be perceived as

posing a potential conflict of interest in the publication of this

article.

The behavioral objectives for this program were created

by Rebecca Holm, MSN, RN, CNOR, clinical editor, with

consultation from Susan Bakewell, MS, RN-BC, director,

Perioperative Education. Ms Holm and Ms Bakewell have

no declared affiliations that could be perceived as posing

potential conflicts of interest in the publication of this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this

article.

DisclaimerAORN recognizes these activities as continuing education for

registered nurses. This recognition does not imply that AORN

or the American Nurses Credentialing Center approves or en-

dorses products mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2012.11.013

� AORN, Inc, 2013

I

Perioperative Nu

rsing Careof the Patient UndergoingBariatric Revision SurgeryJANICE A. NEIL, PhD, RN 3.5

www.aorn.org/CE

ABSTRACT

Obesity has become a major health concern in the United States. The number of

patients seeking bariatric surgery has grown exponentially in recent years because of

the proven success of weight-loss surgery, greater public acceptance, and the

increasing number of insurers who will pay for these surgeries. Patients may seek

bariatric revision procedures if the primary procedure does not achieve the desired

results, if he or she gains back the weight lost after the primary procedure, if the

comorbid conditions associated with obesity were not resolved, or if severe adverse

effects and complications have occurred as a result of the primary bariatric proce-

dure. Perioperative nurses must be knowledgeable about how to care for bariatric

surgery patients with skill and compassion. AORN J 97 (February 2013) 211-226. �AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2012.11.013

Key words: obesity, bariatric surgery, restriction surgery, malabsorptive surgery,

bariatric revision surgery.

n the United States, obesity is the second leading

cause of preventable death related to the co-

morbidities associated with it.1 Lifestyle changes

and dieting rarely produce sustained weight loss

and often are ineffective in achieving long-term

improvement in comorbidities.2 Bariatric surgery

has become an effective method for sustained

weight loss and improvement of obesity-related

comorbid conditions.1,3,4

Patients who have undergone bariatric surgery

may have problems that need to be corrected as a

result of the procedure itself or, more commonly,

they either did not lose the desired amount of weight

or they regained the weight lost from the primary

bariatric procedure. Perioperative nurses must

learn how to care for a potential new population

http://dx.doi.org/10.1016/j.aorn.2012.11.013

� AORN, Inc, 2013

of patientsdthose seeking bariatric revision sur-

gery. This article describes the types of revision

surgery available and the perioperative nursing im-

plications involved in caring for patients undergoing

bariatric surgery. Table 1 defines some common

terms related to bariatric surgery.

BACKGROUND

It is estimated that 32.2% of adult men and 35.5%

of adult women are obese.5 Patients who strongly

desire to lose weight and whose body mass index

(BMI) exceeds 40 kg/m2 are potential candidates for

bariatric surgery. Patients who are severely obese

(ie, with a BMI between 35 kg/m2 and 39 kg/m2)

also can be considered for bariatric surgery if they

have comorbid conditions, such as hypertension,

February 2013 Vol 97 No 2 � AORN Journal j 211

TABLE 1. Glossary of Terms1,2

n Bariatric surgery: A surgical procedure performed forthe purpose of producing weight loss.

n Biliopancreatic limb: The segment of small bowelconnecting the bile duct to the distal end of the Rouxlimb. The segment follows the Roux limb and is thebile-carrying limb.

n Common channel: The segment of small bowel wherethe biliopancreatic limb and the Roux limb becomeone and continue to the cecum. Complex proteins,fats, and carbohydrates are digested in the commonchannel.

n Ergonomics: The science of fitting the demands ofwork to the anatomical, physiological, and psycho-logical capabilities of the worker to enhance efficiencyand well-being.

n Malabsorption: Incomplete digestion or absorption offood intake.

n Morbid obesity: Having a body mass index greaterthan 40 kg/m2.

n Pouch: A surgically created portion of the stomachthat serves as a reservoir for food immediately afterfood exits the esophagus.

n Restrictive: Decreasing or limiting the amount of foodintake.

n Roux limb: The segment of small bowel where foodexits the stomach and enters the bowel. The Rouxlimb starts where food enters the bowel and endswhere the biliopancreatic limb joins to form thecommon channel.

n Staple line: A row of staples placed in the bowel orstomach by a surgical stapling device. Staples can beused to create an anastomosis, create a partition, orsecure the end of a segment of bowel when a sideanastomosis is performed.

1. AORN Bariatric surgery guidelines. In: Perioperative Standards andRecommended Practices. Denver, CO: AORN, Inc; 2010:490.2. Recommended practices for positioning the patient in the peri-operative practice setting. In: Perioperative Standards and Recom-mended Practices. Denver, CO: AORN, Inc; 2012:422.

February 2013 Vol 97 No 2 NEIL

sleep apnea, diabetes mellitus, or musculoskeletal

issues, that interfere with employment and ambula-

tion.6 In addition, people who are obese with lower

BMIs are now seeking weight-loss procedures to

achieve sustained weight loss and prevent comor-

bidities and health-related quality of life issues.7

The number of bariatric procedures performed in

the United States during the past 20 years has

212 j AORN Journal

increased 20% annually.3 Reasons for this increase

include the use of laparoscopic techniques, the

proven success of weight-loss surgery, and in-

creased public acceptance.2 In 1998, 12,775 bari-

atric procedures were performed in the United

States.8 Currently, more than 200,000 procedures

are performed annually in the United States.8 Al-

though this represents only 1% of the eligible,

severely obese population, it is estimated that a

growing number of insurers will have paid for bar-

iatric surgery in 2012, allowing many more people,

even some teens, to benefit from the health advan-

tages of weight-loss surgery.9 With the increased

number of procedures being performed each year,

some patients will seek revision surgery if the

primary procedure did not achieve the desired

results.10,11

All types of bariatric surgery involve restriction

to reduce the quantity of food that can be ingested.

The types of procedures that are only restrictive in

nature include vertical-banded gastroplasty, lapa-

roscopic adjustable banding, and vertical sleeve

gastrectomy. Some types of procedures have both

restrictive and malabsorptive properties (eg, Roux-

en-Y gastric bypass, biliopancreatic diversion with

duodenal switch).2 Malabsorptive-only procedures

that bypass a large portion of the small intestine and

intentionally cause malabsorption by decreasing

absorption of protein and nutrients (eg, jejunoileal

bypass) can produce significant adverse effects, so

they are no longer performed. Figure 1 illustrates the

four most prevalent procedures being performed

today.

CONSIDERATIONS FOR BARIATRICREVISION SURGERY

Although most people are successful in losing large

amounts of weight after bariatric surgery, some

people will need revisions to their primary proce-

dures. People seeking revision surgery may have

inadequate weight loss (ie, they did not lose the

desired amount of weight) or may regain weight

they lost after the primary procedure. Revision

surgery also can treat severe adverse effects and

Figure 1. Illustration of different bariatric procedures: adjustable gastric band (A); gastric bypass (B); gastricsleeve (C); and duodenal switch (D). The dark pink color in the illustration indicates functioning gastrointestinal(GI) tract. The orange-brown color indicates bypassed GI tissues; the green-gray color indicates bypassed andisolated GI tissues (ie, portion of the stomach).

BARIATRIC REVISION SURGERY www.aornjournal.org

complications from the primary bariatric proce-

dure, such as gastrogastric fistulas and pouch dili-

tation.8 Some people may seek revision surgery

because the comorbidities associated with obesity

were not resolved as a result of poor weight loss

or weight regain.

Revision surgery should not be undertaken lightly.

The decision to undergo revision surgery should be

made based on the type of procedure performed in-

itially, the risks and possible benefits of the proposed

procedure, and the person’s condition (eg, comor-

bidities). Generally, a revision procedure presents a

higher risk of postoperative complications than the

first weight-loss procedure because of manipulation

of previously manipulated tissue.8 This can result in

higher mortality and a greater number of adverse

outcomes.8,12

The Longitudinal Assessment of Bariatric Sur-

gery Consortium, a large multisite institutional

group, maintains a database with a wide demo-

graphic profile of patients (eg, patients of both

genders, varying ages and races, multiple co-

morbid conditions) who have had bariatric pro-

cedures. From a study of 255 patients who have

undergone revision surgery, the consortium deter-

mined that adverse outcomes were more likely to

occur with a revision procedure than with a primary

procedure.8 Patients especially at risk include those

with a history of deep vein thrombosis or a preop-

erative diagnosis of sleep apnea.3

Often, the primary reason for bariatric surgery

is to help resolve comorbidities, such as diabetes

mellitus, hypertension, joint pain, and high choles-

terol.2,13 If weight is regained, comorbidities can

return. The solution may be to convert the failed

bariatric procedure to a more metabolically active

type of procedure (eg, one with greater malabsorp-

tive properties). All factors should be examined,

therefore, when revision surgery is being consid-

ered. The risks of revision surgery are outlined

in Table 2.

Research indicates that about 10% of patients

who have bariatric weight-loss procedures experi-

ence unsatisfactory weight loss or will regain some

or all of the weight they lost.14 Frank and Crookes13

estimate that weight regain may be as high as 20%.

AORN Journal j 213

TABLE 2. Risks of Revision Surgery1

n The procedures usually take longerdup to twice aslong as the primary procedure because of the tech-nical difficulty; therefore, patients will require anes-thesia longer.

n Laparoscopic approaches may be more difficult; openincisions may be required because of previous boweland stomach manipulation.

n Generally, there is greater blood loss than with primaryprocedures.2

n Anastomotic leaks and infections occur morefrequently than after the primary procedure.2

n The leak rate increase may be caused by changesin blood flow to the stomach.

n The risk of injury to the intestines is higher becauseof previous manipulation, which may lead to leaksor infections.

n The effect of revision surgery is not as clear as theoriginal procedure. Prediction of the weight loss thatresults from a revision procedure is less accurate. Itis not uncommon to see less weight loss becausemetabolic adaptations that occurred after the originalprocedure may make it more difficult for the patient tolose weight after revision. The patient may be “meta-bolically obstinate,” meaning that his or her metabo-lism may be slower, which may not facilitate quickweight loss.

n Adverse surgical outcomes and medical complicationssuch as deep vein thrombosis, pulmonary embolism,and the need for reintubation are 2.3 times more likelyto occur.2

1. Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity.Cochrane Database Syst Rev. 2009;15(2):CD003641.2. Inabnet WB III, Belle SH, Bessler M, et al. Comparison of 30-dayoutcomes after non-LapBand primary and revisional bariatric surgicalprocedures from the Longitudinal Assessment of Bariatric Surgerystudy. Surg Obes Relat Dis. 2010;6(1):22-30.

February 2013 Vol 97 No 2 NEIL

This inadequate weight loss or weight regain may

be attributed to frequent snacking, high-calorie food

intake, or lack of exercise. Anatomical problems

(eg, a stretched pouch, separated sutures) also can

contribute to weight regain.2

Sometimes, when patients realize what and how

often they are eating, they can get back on track

without surgery. For some, the problem may simply

be noncompliance. The nature of compliance is

complex. Good eating habits are often not part of

normal life for a person who is obese. The person

214 j AORN Journal

may not be able to change his or her eating habits

permanently despite the assistance of a smaller gas-

tric capability.15 The type of surgical procedure

chosen may not have been suitable for the patient

and, as a result, did not work for that patient.

Some of the reasons patients do not lose ade-

quate amounts of weight or regain weight are

the following:

n The procedure performed did not address the

metabolic or mechanical needs of the person.

Weight-loss success involves more than just

eating a nutritional diet, it involves the person’s

metabolic rate. Correcting metabolic failure

involves converting the person’s bariatric sur-

gery type to a more metabolically active type.15

n The anatomical changes of the surgery were

not maintained; thus, mechanical or metabolic

failure occurs. Mechanical failures result when

the anatomical changes made during the primary

procedure are not maintained. These include a

stretched gastric pouch, increased outlet size at

the gastric pouch, formation of a gastrogastric

fistula between the gastric pouch and bypassed

stomach, increased absorptive abilities beyond

expectations, or decreased restriction as a result

of band slippage.16

n The person was unable to adapt to the lifestyle

required for the type of bariatric surgery. This

includes making proper food choices and ex-

ercising.14

n The person was not properly educated on how

to achieve permanent weight loss. When weight

is regained, it is very difficult to lose again.

n Long-term care and support were not provided

or sought to keep the person on track.16

Candidates for revision surgery include those

who have a BMI greater than 35 kg/m2 and those

who failed to achieve 50% of their weight-loss goal

by 18 months after surgery.10 The threshold crite-

rion for revision surgery is weight gain of more

than 10 kg (22 lb).17 However, insurance coverage

for revision surgery is often denied in the United

States for patients who have weight regain without

BARIATRIC REVISION SURGERY www.aornjournal.org

clear-cut problems, such as a mechanical failure.13

Generally, to qualify for initial bariatric surgery

coverage from most insurance companies, the

person must have a BMI of 35 kg/m2 to 39 kg/m2

with two comorbidities or a BMI greater than 40

kg/m2 without comorbidities. Revision surgery

criteria vary according to the problem and are

more stringent.

SPECIFIC PROCEDURES AND REVISIONS

Gastric restrictive procedures include

n Roux-en-Y gastric bypass,

n vertical-banded gastroplasty,

n laparoscopic adjustable banding,

n biliopancreatic diversion with duodenal

switch, and

n vertical sleeve gastrectomy.

These procedures result in a significant reduction

in the stomach size, ensuring early satiety (ie,

satisfied appetite). Patients feel full with a small

quantity of food. Advantages of these procedures

include not only weight loss but also improve-

ment of comorbidities, such as type 2 diabetes

mellitus, hypertension, gastroesophageal reflux

disease, sleep apnea, stress incontinence, and

low back pain.1,15,18 However, there are possible

complications related to each of these proce-

dures. Potential complications and revisions for

each type of bariatric procedure are shown in

Table 3.

Roux-en-Y Gastric Bypass

The Roux-en-Y gastric bypass is the most common

bariatric procedure in the United States,1 comprising

65% of the bariatric surgeries performed.10,13,18 It

has restrictive and malabsorptive properties. During

the procedure, the surgeon creates a small gastric

pouch that holds 15 mL to 30 mL; this restricts food

intake. The gastrojejunostomy provides a mild mal-

absorptive component that also results in weight

loss. The small gastric pouch is joined to the limb

of the jejunum (ie, Roux limb) that is then joined

further down in the jejunum coming from the

duodenum (ie, pancreaticobiliary limb). This forms

a “Y” configuration.19

Bessler et al10 reported an average gastric bypass

failure rate of 15% (ranging from 5% to 40%)

mostly related to weight regain. Mechanical rea-

sons for gastric bypass failure that lead to revision

procedures are gastrogastric fistula, pouch dilata-

tion, anastomotic dilatation, and shortened ali-

mentary segment (Figure 2).

A gastrogastric fistula is a rare complication.20 It

is an abnormal communication between the gastric

pouch and the gastric remnant. The stomach that was

divided during the primary procedure reconnects

via a fistula so the stomach pouch is reconnected

to the bypassed stomach. This often occurs when the

pouch develops a non-acute local inflammation at

the staple line, resulting in a leak that partially re-

verses the gastric bypass. Food can now pass from

the pouch to the bypassed stomach, which is almost

like a reversal of the bypass, and weight regain can

occur.

Although some gastrogastric fistulas can be

treated conservatively, a revision procedure is re-

quired if the person experiences symptoms such

as abdominal pain. Diagnosis of this condition is

made by radiologic study, computed tomography,

and upper endoscopy. Revision surgery involves

closing the fistula to restore the bypassed anat-

omy.20 Repair of this phenomenon can be techni-

cally challenging and can be associated with high

morbidity and mortality. In some situations, endo-

scopic repair can be performed using hemoclips,

fibrin glue, or argon plasma coagulation.21 Fistula

size is often a factor in deciding whether to perform

the procedure endoscopically.

Pouch dilatation occurs when the stomach

pouch stretches and enlarges, thus stretching the

intestine as well. This also can occur at the site

of the anastomosis. Both situations allow for larger

consumption of food. During revision surgery,

the surgeon retrims the pouch to make it smaller.

Transoral endoscopic suturing and plication are

less invasive endoluminal therapies for pouch en-

largement issues.

AORN Journal j 215

TABLE 3. Possible Complications and Revisions for Each Type of Bariatric Procedure

Procedure Complication Potential revision

Roux-en-Y gastric bypass n Gastrogastric fistula: abnormal communi-cation between the gastric pouch and thegastric remnant that allows for largerconsumption of food and, ultimately,weight regain

n Perform revision surgery that involvesclosing the fistula to restore the bypassedanatomy

n Pouch and/or anastomotic dilatation: astretched gastric pouch or an increasein outlet size at the gastric pouch

n Retrim the pouch

n Poor metabolism that leads to weightregain

n Perform a more metabolically activeprocedure (eg, duodenal switch)

Vertical-banded gastroplasty n Band erosionn Stenosis

n Revise to Roux-en-Y or vertical sleevegastrectomy

Laparoscopic adjustable band n Tubing and port issues: twisting, flipping, orleaking of port so that no restriction occurs

n Locate the issue and replace the port

n Band leakage (very rare): leakage at bandbladders with no restriction

n Replace the band

n Poor weight loss/weight regain: restrictionthat is not producing desired weight loss

n Remove the band and convert to aRoux-en-Y gastric bypass, duodenalswitch, or vertical sleeve gastrectomy

Biliopancreatic diversion withduodenal switch

n Inadequate weight loss (rare complication) n Further reduce the stomach size

Vertical sleeve gastrectomy n Sleeve dilatation: the stomach pouch hasstretched or dilated, may be in an “hour-glass” shape

n Resize the sleeve or convert to aRoux-en-Y gastric bypass

n Weight regain, poor weight loss n Convert to a Roux-en-Y gastric bypass orduodenal switch1,2

1. Langer FB, Shakeri-Leidenm€uhler S, Bohdjalian A, et al. Strategies for weight regain after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech.2010;20(3):159-161.2. Keidar A, Appelbaum L, Schweiger C, Elazary R, Baltasar A. Dilated upper sleeve can be associated with severe postoperative gastroesophagealdysmotility and reflux. Obes Surg. 2010;90(2):140-147.

February 2013 Vol 97 No 2 NEIL

Injecting sodium morrhuate around the dilated

stoma is also a method to reduce stoma size in

response to anastomotic dilatation.10 Endoscopic

fixation is an approach to remedy this problem

aimed at restoring the smaller pouch. Performing

a vertical sleeve gastrectomy-type procedure is

another option, especially if the gastric bypass is

complicated by nutrient malabsorptive issues, such

as osteoporosis and anemia.

Adjustable banding may be another option for

revising a gastric bypass. A band is placed around

216 j AORN Journal

the proximal pouch and adjusted six weeks later

and as necessary. This is an attractive approach

because it requires no anastomosis, and no change

in absorption occurs. Whereas some revision pro-

cedures are technically complex, challenging, and

associated with a variety of postoperative compli-

cations, an adjustable band is an easier approach

and may be the solution to correct weight regain.10

A shortened alimentary segment, although a rare

complication, also can occur. Normally, the segment

that comes from the gastric pouch is approximately

Figure 2. Anatomical causes of weight regain ingastric bypass: dilated anastomosis or dilated pouch;gastrogastric fistula; or short alimentary segment.The dark pink color in the illustration indicatesfunctioning gastrointestinal (GI) tract. The orange-brown color indicates bypassed GI tissues.

BARIATRIC REVISION SURGERY www.aornjournal.org

100 cm to 150 cm in length. The length is variable

and can be affected by anesthetics. Preoperative

medications and anesthetics can cause the portion

of the small bowel used for the segment to contract.

The alimentary segment may have shortened be-

cause it contracted or adhesions are present (W.

Pories; past president, American Society for Bari-

atric Surgery and professor of surgery, East Caro-

lina University; oral communication; April 12,

2012). The revision surgery to correct this involves

lengthening the limb by moving the biliopancreatic

limb down further in the jejunum.22 However, pa-

tients must be watched more closely for protein

malnutrition with a more distal Roux-en-Y.23

In some situations of weight regain, a more

metabolically active approach can be taken by

changing to a duodenal switch. This approach

addresses inadequate weight loss by correcting

metabolic failure and maladaptive eating because

of the increased malabsorptive properties of this

procedure. There is less absorption of food, so

weight can be lost. However, a potential concern

is proper stomach functioning after surgery. The

bypassed stomach is brought back to use, but in

some situations, the nerves were cut during the

primary procedure. In time, the nerves may re-

generate and become active again. In some cases,

excessive scar tissue makes it unsafe to reconnect

the gastric pouch to the bypassed stomach. Revi-

sion to a biliopancreatic diversion is technically

complex and, as a result of significant malabsorp-

tion, protein malnutrition and vitamin and iron

deficiencies can occur.

Vertical-Banded Gastroplasty

Vertical banding involves partitioning and stapling

the fundus of the stomach. Although this was a

common bariatric procedure in the past, adjustable

gastric banding has replaced it.24 Band erosion

and stenosis are late complications. Optional revi-

sions include revising to a Roux-en-Y or vertical

sleeve gastrectomy.15

Laparoscopic Adjustable Banding

The laparoscopic adjustable band was introduced

in 1993. This procedure is restrictive in nature. A

silicone band with an inflatable inner collar is placed

around the upper stomach. The band is connected to

a port that is placed in the soft tissue of the abdomen.

The inner diameter of the band can be adjusted

later using bimanual palpation of the abdominal

port and injecting saline into the port to create more

restriction.1

Data suggest that patients lose an average of more

than 50% of excess weight.1 Excess weight is

defined as the starting weight minus the goal weight.

Currently, about 25% of bariatric surgery proce-

dures involve gastric banding.4,13,25 This procedure

has a very good perioperative safety record, very

low mortality, and a beneficial effect on comorbid-

ities related to the weight loss, and it is minimally

invasive and reversible. In 2011, the US Food and

AORN Journal j 217

February 2013 Vol 97 No 2 NEIL

Drug Administration released a statement that

expanded the use of the laparoscopic adjustable

band system to include people with BMIs in the

30 kg/m2 to 34 kg/m2 range, especially for those

who have at least one comorbidity.26

Weight regain is the usual reason for revision.

Because it does not make anatomical changes, the

laparoscopic adjustable band is considered a device

that influences eating behaviors by acting as a tool

to decrease food intake. However, patients may

have eating behaviors incompatible with the band.

These include sweet eating (ie, eating foods high in

sugar) and grazing (eg, eating smaller quantities of

food at frequent intervals).15 Tubing and port issues

(eg, tube disconnection, port leakage) can result in

poor weight loss or weight regain. A patient with

a laparoscopic adjustable band who had adequate

restriction may lose that restriction if the band de-

velops a leak, which can happen suddenly or over

time. If the band leaks, the band may not be able to

be filled properly and will not provide restriction.

People with this issue often feel a loss of restriction

or a change in the restriction. This may be accom-

panied by weight regain or inability to lose more

weight because they can eat larger volumes of food.4

There are four likely sites for band leakage:

n The band balloon around the stomach may leak

as a result of factory defects causing a weak

point or a needle puncture occurring uninten-

tionally during surgery (a very rare occurrence,

especially with the newer bands).

n The tube connection may leak as a result of

a break or fracture of the tube next to the metal

connection where the tubing connects to the

port. This can happen as a result of physical

movement over time.

n The body of the tube may leak; this is usually

caused by unintentional needle punctures when

the band is filled. There is always a risk of punc-

turing the tube with an adjustment even in the

best of circumstances, including when fluoros-

copy is used for port visualization. The band and

the port can both be visualized by fluoroscopy.

218 j AORN Journal

n The port membrane can leak if the port has been

accessed multiple times or if a Huber needle

was not used for the fill. The silicone part of the

port can be damaged if any other type of needle

is used.27

If any of these situations occur, the part of the band

system that is leaking can be replaced or the entire

band can be replaced.

The laparoscopic adjustable band is removable

and can be converted to a Roux-en-Y gastric bypass

or duodenal switch in patients for whom the band

did not have the desired effects. The Roux-en-Y

gastric bypass is the most commonly performed

revision for poor weight loss. Topart et al found

that nearly 40% of patients with laparoscopic bands

had a five-year failure rate.28 Some people may not

have a high enough metabolism needed to lose

weight with the band or have the proper eating

habits to ensure success. Metabolically, more active

types of surgery instead of restrictive types of sur-

gery may produce the desired weight-loss goals in

these patients. However, converting to a gastric

bypass may put the person at risk for an anasto-

motic leak. The vertical sleeve gastrectomy and

the duodenal switch with ileal transposition may

also be choices for revision because of their

metabolic properties that cause weight loss in

addition to restrictive properties. Figure 3 shows

the possible revision procedures for a laparoscopic

band. Sometimes the band is removed in one

procedure, and after healing occurs, the new

procedure is performed.

Biliopancreatic Diversion With DuodenalSwitch

The biliopancreatic diversion with duodenal switch

has significant malabsorptive and restrictive prop-

erties. The patient is able to eat normally while

developing a metabolism similar to that of a lean

person. The surgery has three components:

n removing a large portion of the stomach to

promote smaller meal sizes (ie, vertical gastric

sleeve),

Figure 3. Options to revise a failed laparoscopicband: convert the band to a gastric sleeve or con-vert the band to a gastric bypass. The dark pink colorin the illustration indicates functioning gastrointes-tinal (GI) tract. The orange-brown color indicatesbypassed GI tissues; the green-gray color indicatesbypassed and isolated GI tissues (ie, portion of thestomach).

BARIATRIC REVISION SURGERY www.aornjournal.org

n re-routing the food away from the small intes-

tine to partially prevent absorption of food, and

n re-routing bile and other digestive juices, which

impairs digestion.14

The procedure begins with a vertical sleeve gas-

trectomy that reduces the patient’s stomach size to

90 mL to 120 mL.14,19 This leaves a vertical tube

with the pylorus intact. The remainder of the stom-

ach is removed. Beyond the pylorus, the duodenal

segment is divided and the proximal end is anasto-

mosed to a section of ileum to become the “alimen-

tary channel.” This segment is then anastomosed to

the segment coming from the duodenum at an area

50 cm to 100 cm from the ileocecal valve. This

very short tract is where food is digested and ab-

sorbed, which causes 90% of the intestines to be

bypassed, resulting in major malabsorptive effects.

The biliopancreatic diversion with duodenal

switch leaves 75 cm to 100 cm of small bowel

available for absorption of nutrients.15 This effec-

tively re-routes the small bowel so less food is ab-

sorbed. Excess fat and carbohydrates are present in

the stool, leading to two to four bowel movements

a day.15 This surgery achieves major weight loss

and the least amount of weight regain of all the

procedures, but it has the highest complication rate.

Protein and vitamin supplements are essential

for persons who have this type of surgery because

so much of the small bowel is bypassed. The sur-

gery is also excellent for decreasing or alleviating

comorbidities because the person’s diabetes melli-

tus, hypertension, gastroesophageal reflux disease,

sleep apnea, and osteoarthritis often are improved

or eliminated. However, the food is bypassing most

of the duodenum, which can lead to malabsorption.

Vitamin and mineral deficiencies can occur as a

result.

Duodenal switch is the most aggressive type

of bariatric surgery and, therefore, has the highest

potential for complications. The duodenal switch

more likely results in excessive weight loss rather

than inadequate weight loss. In the rare case that

there is weight regain after this procedure, it may

be a result of snacking or grazing behaviors where

there is intake of food at frequent intervals. Only

2% to 5% of duodenal switch patients require re-

vision weight-loss surgery. With the assumption

that nonsurgical weight-loss attempts have been

tried and failed, there are two theoretical approaches

to solve this problem: reduce the stomach size or

shorten the length of the common limb. Although

the results of these two revisions vary, reductions

in stomach size seem to generate superior results

over shortening the length of the common limb.15

Vertical Sleeve Gastrectomy

The vertical sleeve gastrectomy is a restrictive

procedure that reduces the stomach size by 85%

through stapling and removal of the portion of the

stomach that has been walled off.14 This leaves the

pylorus and nerve supply intact, thus avoiding

AORN Journal j 219

February 2013 Vol 97 No 2 NEIL

complications, such as anemia and vitamin defi-

ciencies. There is no bypass of the intestinal tract.

Another benefit is that the portion of the stomach

that secretes ghrelin (ie, a hunger-producing hor-

mone) is removed.17 Historically, the vertical sleeve

gastrectomy had been performed as the first stage

of a biliopancreatic diversion. Now it is performed

alone. This procedure restricts food intake and does

not lead to decreased absorption of food.

Patients often seek revisions of this type of sur-

gery because of weight regain. Dilatation of the

narrow sleeve can occur that results in an increased

capacity for food. Conversion to more metaboli-

cally active types of procedures may be the solu-

tion if restriction alone did not result in adequate

weight loss. Revisions to the sleeve gastrectomy

include sleeve resizing, extending the procedure to

a duodenal switch, or converting to a Roux-en-Y

gastric bypass.17 In fact, the vertical sleeve is the

first step of the duodenal switch procedure, so when

converting to a duodenal switch, a significant

portion of the procedure has already been per-

formed. Stomach stretching may occur in a uni-

form way, producing an hourglass configuration

where the top and bottom of the stomach are large,

separated by a narrower part. This causes an un-

comfortable feeling when the patient consumes

food and may be a reason for revision. Another

possibility is placing an adjustable band to add

more restriction.

PERIOPERATIVE NURSING CARE

AORN’s perioperative standards and recommended

practices explain that the morbidly obese pop-

ulation presents special challenges. These stan-

dards provide recommendations for practice that

include creating the proper environment for the

unique psychosocial and physiological needs of

this patient population.29 The bariatric standards

are based on those set by the National Institutes

of Health and the American Society of Bariatric

Surgeons. The standards for selecting bariatric

surgery patients include the following6:

220 j AORN Journal

n performing an in-depth, preoperative assess-

ment of the patient’s risks and surgical benefits;

n selecting a well-informed, motivated patient

who presents acceptable surgical risks;

n selecting a patient based on a low probability of

weight-loss success without a bariatric proce-

dure; and

n choosing a procedure based on the patient’s

functional impairments and comorbidities.

Nurses should realize that patients having revision

surgery may have psychological or social factors that

prevented them from losing adequateweight. Seeking

revision surgery is evidence that the person is at-

tempting to address these issues. Others are having

revision surgery because of complications that have

occurred as a result of the primary weight-loss

procedure that have now resulted in weight regain.

Patients who are obese often have had negative

psychosocial interactions and humiliating experi-

ences with insensitive care providers, so perioper-

ative team members should take care to prevent

this from occurring.30 Perioperative nurses should

prepare a care plan specific to the patient who is

undergoing bariatric revision surgery (Table 4).

Preoperative Nursing Care

Using the Perioperative Nursing Data Set can help

perioperative nurses develop individualized plans

of care based on the needs of patients who are

obese or morbidly obese. The outcome indicators

should include the patient’s knowledge about the

surgery, accurate clinical documentation, sup-

portive resources, and patient satisfaction.31

Obesity has adverse effects on most body sys-

tems. Care begins with a thorough and accurate

assessment. The preoperative nurse should review

the patient’s medical history and physical exami-

nation results and should identify the primary

bariatric procedure and determine whether the

possible reasons for failure were addressed. Pre-

existing respiratory, circulatory, neurological, skin,

and immune system problems should be noted.

Routine skin assessment may be difficult because

TABLE 4. Nursing Care Plan for a Patient Undergoing Bariatric Revision Surgery

Diagnosis Nursing interventionsInterim outcome

statement Outcome statement

Nausea; risk for deficient fluidvolume

n Identifies baseline gastro-intestinal status.

n Identifies physiologicalstatus.

n Reports deviation in diag-nostic study results.

n Monitors physiologicalparameters.

n Evaluates gastrointestinalstatus.

n The patient is NPO asinstructed preoperatively.

n The patient is free fromnausea and vomiting.

n The patient can tolerateclear liquid by mouth beforedischarge postoperatively.

n The patient’s gastrointes-tinal status is maintained ator improved from baselinelevels.

Imbalanced nutrition: less thanbody requirements; imbal-anced nutrition: more thanbody requirements

n Identifies baseline gastro-intestinal status.

n Assesses nutritional habitsand patterns.

n Assesses psychosocialissues specific to thepatient’s nutritional status.

n Includes the patient ordesignated support personin perioperative teaching.

n Provides instructionregarding dietary needs.

n Evaluates response toinstructions.

n Evaluates response tonutritional instruction.

n The patient verbalizescompliance with food andfluid restrictions beforesurgery.

n The patient describesappropriate home man-agement of symptomsthat affect nutritional intake(eg, sore throat, nausea,vomiting) at the time ofdischarge.

n The patient describesthe recommendedpostoperative nutritionalintake regimen for therecovery period at thetime of discharge.

n The patient or designatedsupport person demon-strates knowledge of nutri-tional management relatedto the operative or invasiveprocedure.

Risk for perioperative posi-tioning injury; risk forimpaired skin integrity

n Assesses baseline skincondition.

n Identifies baseline tissueperfusion.

n Identifies baseline muscu-loskeletal status.

n Identifies physical alter-ations that require addi-tional precautions forprocedure-specificpositioning.

n Positions the patient.n Implements protective

measures to prevent skin ortissue injury caused bymechanical sources.

n Applies safety devices.n Evaluates tissue perfusion.

n The patient’s pressurepoints demonstrate hyper-emia for less than 30minutes.

n The patient’s peripheraltissue perfusion is consis-tent with preoperativestatus at discharge from theOR or procedure room.

n The patient is free from painor numbness associatedwith surgical positioning.

n The patient is free fromsigns and symptoms ofinjury related to positioning.

(table continued)

AORN Journal j 221

BARIATRIC REVISION SURGERY www.aornjournal.org

TABLE 4. (continued) Nursing Care Plan for a Patient Undergoing Bariatric Revision Surgery

Diagnosis Nursing interventionsInterim outcome

statement Outcome statement

n Evaluates musculoskeletalstatus.

n Evaluates for signs andsymptoms of physical injuryto skin and tissue.

Deficient knowledge; impairedphysical mobility; ineffectivefamily therapeutic regimenmanagement

n Identifies patient’s anddesignated supportperson’s educationalneeds.

n Identifies expectations ofhome care.

n Includes the patient ordesignated support personin perioperative teaching.

n Provides instruction basedon age and identifiedneeds.

n Evaluates environment forhome care.

n Evaluates response toinstructions.

n The patient voices con-cerns related to post-operative recovery andrehabilitation.

n The patient and designatedsupport person verbalizerealistic expectationsregarding rehabilitationafter surgery.

n The patient verbalizes signsand symptoms to reportimmediately to the surgeon.

n The patient describes theprescribed rehabilitationregimen to follow immedi-ately after discharge fromthe facility.

n The patient participates inthe rehabilitation process.

February 2013 Vol 97 No 2 NEIL

of extra skin folds, lack of landmarks, or chronic

skin conditions. The nurse should document in-

formation on the patient’s age, height, weight,

BMI, skin condition, nutritional status, and aller-

gies. A thorough medication history that includes

what vitamins and herbs the patient is taking is

also essential.

In addition, the nurse should review the patient’s

laboratory test results. Pulmonary function tests and

arterial blood gas results along with ventilation/

perfusion scans often are performed, and the nurse

should ensure that the results are on the patient’s

preoperative chart. The preoperative nurse should

note abnormalities and include them in the plan

of care as well as share concerns with the anesthesia

professional and surgeon. Recent advances in the

care of the bariatric patient include the use of

clinical pathways. The development of ergonomic

technology and use of special bariatric equipment

have improved safety for staff members and

222 j AORN Journal

patients. The nurse should ensure that this equip-

ment is available to safely care for the patient. The

nurse should note whether the patient has any

physical limitations and mobility issues.

The issues of immobility and increased risk for

deep vein thrombosis are always present, especially

in patients who are obese. Prophylaxis may include

administration of low-molecular-weight heparin,

use of thromboembolic device stockings, use of

sequential compression device leggings, and place-

ment of a vena cava filter, particularly for patients

with a history of deep vein thrombosis or hyper-

coagulable states or for those who will not be able

to ambulate easily after surgery. In addition, the

surgeon may request an endocrine evaluation that

includes the status of the patient’s diabetes mellitus.

Skin integrity requires careful assessment. The

nurse should look for areas of irritation, infection,

and ulceration, including under skin folds. The

patient who is morbidly obese may have atypical

BARIATRIC REVISION SURGERY www.aornjournal.org

pressure areas that could lead to pressure sores.

People who have lost large amounts of weight may

have redundant skin, which can result in excessive

skin folds that are areas for potential skin break-

down, particularly in people who have difficulty

performing adequate hygiene. Nurses should assess

the patient’s skin condition for color, edema, evi-

dence of previous surgery (eg, scars), moisture, evi-

dence of fragile tissue, obvious lesions or wounds,

temperature, texture, turgor, and vascularity.31

Intraoperative Nursing Care

In many institutions, designated teams work with

bariatric surgeons on a regular basis. If the patient

has a BMI greater than 35 kg/m2, this should be

noted on the OR schedule so adequate preparations

can be made, including obtaining proper equip-

ment.30 The circulating nurse also should ensure

that adequate personnel are available to safely

move and position the patient.

Positioning is of the upmost importance not only

to prevent injury to pressure areas, but also to ensure

maximum respiratory excursion. Safety consider-

ations for positioning the patient who is morbidly

obese include the following32,33:

n The procedure bed should be able to articulate

and support a patient weighing 800 lb to 1,000 lb.

n Specialized hydraulics capable of lifting pa-

tients weighing as much as 1,000 lb should be

available.

n The mattress should provide sufficient support

and padding and not sag under the weight of the

patient.

n The width of the patient’s legs determines

whether the legs will remain on the bed or

be supported by stirrups or side attachments.

n The patient’s arms may need to be placed in

padded toboggans to support them at the sides

of the patient’s body.

n Extra wide and long safety straps should be

available. In some situations, two safety straps

may be needed, one over the patient’s thighs

and one over the patient’s lower legs. Sheets

should not be used as substitutes for safety

straps.

n If the patient is placed in the supine position,

a roll or wedge may need to be placed under the

right flank to relieve compression on the vena

cava.

n Placing the patient in the Trendelenburg posi-

tion should be avoided because the added

weight of the abdominal contents against the

diaphragm may result in respiratory compro-

mise. Vascular congestion can result if the pa-

tient is placed in the Trendelenburg position

because the blood from the patient’s lower

extremities moves into the central and pulmo-

nary circulation.

n When using reverse Trendelenburg, the circu-

lating nurse should align the patient’s feet flat

on the foot board to prevent rotation and pres-

sure on the patient’s ankles.

A patient who is obese may have decreased chest

wall compliance, increased respiratory resistance,

decreased lung volume and residual capacity, and

increased oxygen consumption. The patient may

have a short, thick neck that can make intubation

more difficult, and he or she may experience rapid

oxygen desaturation. The circulating nurse should

obtain the difficult airway cart, fast-track laryngeal

mask airway, and a direct-visualization intubating

scope used for people with respiratory problems

that may involve difficult intubation. A patient can

experience hypoxia rapidly compounded by the

pressure on the diaphragm from body fat when

lying supine. There is an increased risk for aspira-

tion as well, so the anesthesia professional must

take care to prevent the patient from aspirating.34

Postoperative Nursing Care

The postanesthesia care unit (PACU) nurse should

carefully assess and monitor the patient’s respira-

tory status, including respiratory patterns and rate,

depth, and ease of breathing, because patients who

are obese are more prone to respiratory failure.2

The nurse should help the patient with deep breathing

AORN Journal j 223

February 2013 Vol 97 No 2 NEIL

and coughing exercises and should administer oxy-

gen as ordered. The patient may need bilevel positive

airway pressure or continuous positive airway pres-

sure. Some facilities allow patients to bring their own

masks if they use continuous positive airway pres-

sure at home.

Positioning also is important. The standard supine

and Trendelenburg positions should be avoided

because the weight of the abdominal contents com-

pressing the diaphragm makes breathing more dif-

ficult. The PACU staff should work together to place

the patient in a sitting position at a 45-degree angle

or the lateral position. Care must be taken when

The exponential increase in bariatric surgerywill result in the need for more revisionprocedures and present new challengesfor perioperative nurses.

a patient is in the

lateral position if the

patient has a large

panniculus (eg, a dense

layer of fatty tissue

growth consisting of

subcutaneous fat in the

lower abdominal area).

Staff members can displace the panniculus to the

side with support under it. Staff members should

remember that when a patient turns over, he or she

has an increased risk of falling if the panniculus

shifts. Extra wide stretchers or beds should be used

if available.

Postoperative care involves assessment and

identification of complications. Immediate post-

operative complications, such as anastomotic leaks,

often are manifested by tachycardia.

The patient should ambulate as soon as possible

and the nurse should ensure that proper equipment

is available for helping to lift and position the pa-

tient. Venous thromboembolism is also more prev-

alent in patients who are obese, so ambulation and

physical activity are important. The PACU nurse

should assess the patient for signs and symptoms of

venous thromboembolism (eg, pain or tenderness,

swelling, warmth, or redness in one leg or both

legs) and should include information about this

in the postoperative teaching materials.

The PACU staff should use equipment marked

with weight capacity to ensure safety for the patient

224 j AORN Journal

and staff members.16 People who are obese often

have poor posture that can result in pain, especially

in the spine, knees, and feet. They also have a slower

gait.35 The PACU staff should take special care

when transferring the patient to a wheelchair or

assisting with ambulation. It is best to allow the

patient to move without assistance as much as

possible. The PACU nurse should perform a thor-

ough postoperative skin assessment, noting any

changes from baseline.

The PACU nurse may need to crush medica-

tions into a powder form or use liquid preparations

of the medications because of the reduced size of

the patient’s stomach.

For outpatient proce-

dures, early moni-

toring of pain, activity

level, respiratory

status, urinary output,

fluid tolerance, and

ability to comply with

the medication regimen should be assessed.

For patients with diabetes, the nurse should

measure blood glucose levels at regular, prescribed

intervals while the patient is in the hospital and

instruct the patient to measure his or her blood

glucose levels after discharge. At discharge, the

American Society of Bariatric Surgeons recom-

mends that surgeons follow up with patients at

frequent intervals and should assess the patient’s

weight loss, presence of complications, and status

of comorbities.6 Typically, follow-up occurs with

the initial postoperative visit and then at three-, six-,

and 12-month intervals; after that, patients have

annual appointments. Health care providers should

encourage the patient to find and participate in sup-

port groups or motivational forums.

CONCLUSION

The popularity of bariatric surgery and its expo-

nential increase will result in the need for more

revision procedures to be performed. This will

present new challenges for perioperative nurses

and other health care providers. Postoperative

BARIATRIC REVISION SURGERY www.aornjournal.org

complications may necessitate revision; however,

the most common reasons for revision surgery are

failure to lose the desired amount of weight, regain

of weight lost, or metabolic issues related to the

procedure itself. Further investigation is needed

related to the appropriate interventional methods

for each type of problem and the inherent limita-

tions of the current evidence base for sustained

bariatric surgery success. It is important to develop

strategies to optimize the effectiveness of revi-

sion procedures and nursing care of bariatric

patients.

References1. Kasza J, Brody F, Vaziri K, et al. Analysis of poor

outcomes after laparoscopic adjustable gastric banding.

Surg Endosc. 2011;25(1):41-47.

2. Apau D, Whiteing N. Pre- and post-operative nursing

considerations of bariatric surgery. Gastrointest Nurs.

2011;9(3):44-48.

3. Longitudinal assessment of bariatric surgery (LABS).

How many people have had bariatric surgery? January

2010. Weight-Control Information Network. National

Institute of Diabetes and Digestive and Kidney Diseases.

http://win.niddk.nih.gov/publications/labs.htm#howmany.

Accessed September 14, 2012.

4. Ardestani A, Lautz DB, Tavakkolizadeh A. Band revi-

sion versus Roux-en-Y gastric bypass conversion as

salvage operation after laparoscopic adjustable gastric

banding. Surg Obes Relat Dis. 2011;7(1):33-37.

5. Overweight and obesity statisticsdoverweight and obe-

sity prevalence estimates. Weight-Control Information

Network. National Institute of Diabetes and Digestive and

Kidney Diseases. http://win.niddk.nih.gov/statistics/index

.htm#overweight. Updated February 2010. Accessed

September 14, 2012.

6. Rationale for surgical treatment of morbid obesity.

American Society for Metabolic & Bariatric Surgery.

http://asmbs.org/rationale-for-surgical-treatment. Upda-

ted November 23, 2005. Accessed September 14, 2012.

7. Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery

for obesity. Cochrane Database Syst Rev. 2009;15(2):

CD003641.

8. Inabnet WB III, Belle SH, Bessler M, et al. Comparison

of 30-day outcomes after non-LapBand primary and re-

visional bariatric surgical procedures from the Longitu-

dinal Assessment of Bariatric Surgery study. Surg Obes

Relat Dis. 2010;6(1):22-30.

9. Bariatric surgery forecasts for 2010. HealthNewsDigest

.com http://www.healthnewsdigest.com/news/Forecast

_630/10_Bariatric_Surgery_Forecasts_for_2010.shtml.

Accessed September 14, 2012.

10. Bessler M, Daud A, DiGiorgi MF, et al. Adjustable

gastric banding as revisional bariatric procedure after

failed gastric bypassdintermediate results. Surg Obes

Relat Dis. 2010;6(1):31-35.

11. Ryou M, Mogabgab O, Lautz DB, Thompson CC. Endo-

scopic foreign body removal for treatment of chronic ab-

dominal pain in patients after Roux-en-Y gastric bypass.

Surg Obes Relat Dis. 2010;6(5):526-531.

12. Hallowell PT, Stellato TA, Yao DA, Robinson A,

Schuster MM, Graf KN. Should bariatric revisional

surgery be avoided secondary to increased morbidity

and mortality? Am J Surg. 2009;197(3):391-396.

13. Frank P, Crookes PF. Short- and long-term surgical

follow-up of the postbariatric surgery patient. Gastro-

enterol Clin North Am. 2010;39(1):135-146.

14. Bariatric surgery for severe obesity. Weight-Control

Information Network. National Institute of Diabetes

and Digestive and Kidney Diseases. http://win.niddk

.nih.gov/publications/gastric.htm. Accessed September

14, 2012.

15. Husted J. Revision weight loss surgery. WLS Revi-

sions Forum. ObesityHelp. http://www.obesityhelp.com/

forums/revision/revision-weight-loss-surgery.html. Sep-

tember 14, 2012.

16. Mulligan AT, McNamara AM, Boulton HW, Trainor LS,

Raiano C, Mullen A. Best practice updates for nursing

care in weight loss surgery. Obesity (Silver Spring). 2009;

17(5):895-900.

17. Langer FB, Shakeri-Leidenm€uhler S, Bohdjalian A, et al.

Strategies for weight regain after sleeve gastrectomy. Surg

Laparosc Endosc Percutan Tech. 2010;20(3):159-161.

18. Kurian MS, Thompson B, Davidson BK. Weight Loss

Surgery for Dummies. Hoboken, NJ: Wiley Publishing,

Inc; 2005:352.

19. Ide P, Farber ES, Lautz D. Perioperative nursing care of the

bariatric surgical patient. AORN J. 2008;88(1):30-54.

20. Maselli R, Rizzello M, Genco A, Fantini A, Basso N. Lap-

aroscopic sleeve gastrectomy as revisional surgery in a

vertical gastroplasty with gastrogastric fistula: a simplified

technique. Surg Laparosc Endosc Percutan Tech. 2011;

21(1):e4-e6.

21. Fernandez-Esparrach G, Lautz DB, Thompson CC. En-

doscopic repair of gastrogastric fistula after Roux-en-Y

gastric bypass: a less-invasive approach. Surg Obes Relat

Dis. 2010;6(3):282-288.

22. Feng JJ, Gagner M, Pomp A, et al. Effect of standard vs

extended Roux limb length on weight loss outcomes after

laparoscopic Roux-en-Y gastric bypass. Surg Endosc.

2003;17(7):1055-1060.

23. Fobi MA, Lee H, Igwe D Jr, et al. Revision of failed

gastric bypass to distal Roux-en-Y gastric bypass:

a review of 65 cases. Obes Surg. 2001;11(2):190-195.

24. Tevis S, Garren MJ, Gould JC. Revisional surgery for

failed vertical-banded gastroplasty. Obes Surg. 2011;

21(8):1120-1124.

25. More number of obese adults are turning to bariatric

surgery as a last resort, says WHO. December 9, 2009.

News Medical. http://www.news-medical.net/news/2009

1209/More-number-of-obese-adults-are-turning-to-baria

tric-surgery-as-a-last-resort-says-WHO.aspx. Accessed

September 14, 2012.

26. FDA expands use of banding system for weight loss. US

Food and Drug Administration. http://www.fda.gov/

NewsEvents/Newsroom/PressAnnouncements/ucm245617

.htm?sms_ss¼email&at_xt¼4d7a6ccec62ec632,0. Upda-

ted March 3, 2011. Accessed September 14, 2012.

AORN Journal j 225

February 2013 Vol 97 No 2 NEIL

27. Rodriguez A. LapBand leaks: what you should know.

http://arturorodriguezmd.com/lap-band-leaks. Updated

March 7, 2009. Accessed September 14, 2012.

28. Topart P, Becouarn G, Ritz P. Biliopancreatic diversion

with duodenal switch or gastric bypass for failed gastric

banding: retrospective study from two institutions with

preliminary results. Surg Obes Relat Dis. 2007;3(5):

521-525.

29. AORN Bariatric surgery guidelines. In: Perioperative

Standards and Recommended Practices. Denver, CO:

AORN, Inc; 2010:490.

30. Graham D, Faggionato E, Timberlake A. Preventing

perioperative complications in the patient with a high

body mass index. AORN J. 2011;94(4):334-347.

31. Petersen C, ed. Perioperative Nursing Data Set: The

Perioperative Nursing Vocabulary. 3rd ed. Denver, CO:

AORN, Inc; 2011:2.

32. Recommended practices for positioning the patient in

the perioperative practice setting. In: Perioperative

226 j AORN Journal

Standards and Recommended Practices. Denver, CO:

AORN, Inc; 2012:421-444.

33. Dybec RB. Intraoperative positioning and care of the

obese patient. Plast Surg Nurs. 2004;24(3):118-122.

34. Brodsky JB. Positioning the morbidly obese patient for

anesthesia. Obes Surg. 2002;12(6):751-758.

35. Fabris de Souza SA, Faintuch J, Valezi AC, et al. Pos-

tural changes in morbidly obese patients. Obes Surg.

2005;15(7):1013-1016.

Janice A. Neil, PhD, RN, is an associate pro-

fessor at East Carolina University, College of

Nursing, Greenville, NC.Dr Neil has no declared

affiliation that could be perceived as posing

a potential conflict of interest in the publication

of this article.

EXAMINATION

CONTINUING EDUCATION PROGRAM

3.5

www.aorn.org/CEPerioperative Nursing Care of

the Patient Undergoing BariatricRevision Surgery

PURPOSE/GOAL

�

The purpose of this activity is to enable the learner to more effectively care for

patients undergoing bariatric revision surgery.

OBJECTIVES

1. Describe types of bariatric surgery.

2. Explain why people undergo bariatric revision surgery.

3. Discuss complications that patients undergoing bariatric revision surgery may

experience.

4. Identify safety precautions that perioperative nurses should institute for patients

undergoing bariatric revision surgery.

The Examination and Learner Evaluation are printed here for your conven-

ience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. All types of bariatric surgery involve _________

to reduce the quantity of food that can be

ingested.

a. absorption b. restriction

AORN, Inc, 2013

c. absorption and restriction

2. People seek revision bariatric surgery

1. because they experienced inadequate weight

loss after the primary bariatric procedure.

2. because they regained weight they lost after

the primary bariatric procedure.

3. to treat severe adverse effects and compli-

cations from the primary bariatric procedure.

4. because the comorbidities associated with

obesity were not resolved after the primary

bariatric procedure.

a. 1 and 3 b. 2 and 4

February 2013 Vo

c. 1, 2, and 4 d. 1, 2, 3, and 4

3. Mechanical failures that result when the anat-

omical changes made during the primary proce-

dure are not maintained include

1. a stretched gastric pouch.

2. increased outlet size at the gastric pouch.

3. formation of a gastrogastric fistula between

the gastric pouch and bypassed stomach.

4. increased absorptive abilities beyond

expectations.

l 97 No 2 � AORN Journal j 227

February 2013 Vol 97 No 2 CE EXAMINATION

5. decreased restriction as a result of band

slippage.

a. 4 and 5 b. 1, 2, and 3

228 j AORN Journal

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

4. The threshold criterion for revision surgery is

weight gain of more than 20 kg (44 lb).

a. true b. false

5. The most common bariatric procedure in the

United States is the

a. biliopancreatic diversion with duodenal

switch.

b. laparoscopic adjustable band.

c. Roux-en-Y gastric bypass.

d. vertical-banded gastroplasty.

6. To resolve a dilated pouch or stoma, the surgeon

may

1. inject sodium morrhuate around the dilated

stoma.

2. move the biliopancreatic limb down further

in the jejunum.

3. perform endoscopic fixation.

4. perform a vertical sleeve gastrectomy-type

procedure.

a. 1 and 3 b. 2 and 4

c. 1, 3, and 4 d. 1, 2, 3, and 4

7. During a vertical sleeve gastrectomy, the part of

the stomach that produces ghrelin, a hormone that

_____________________________, is removed.

a. decreases taste sensitivity

b. produces hunger

c. promotes weight gain

d. stimulates salivary production

8. Prophylaxis for patients with a history of deep vein

thrombosis or hypercoagulable states may include

1. administration of low-molecular-weight

heparin.

2. placement of a vena cava filter.

3. use of sequential compression device

leggings.

4. use of thromboembolic device stockings.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 4 d. 1, 2, 3, and 4

9. Safety considerations for positioning a patient

who is morbidly obese may include

1. employing the Trendelenburg position

whenever possible to shift the patient’s

excess abdominal skin out of the way.

2. placing a roll or wedge under the right

flank if the patient is placed in the supine

position.

3. placing the patient’s arms in padded

toboggans to support them at the sides

of the patient’s body if needed.

4. using sheets as substitutes for safety straps if

needed.

5. using stirrups or side attachments to support

the patient’s legs if needed.

a. 4 and 5 b. 2, 3, and 5

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

10. Immediate postoperative complications, such as

anastomotic leaks, are often manifested by

a. bloody emesis.

b. bradycardia.

c. rebound tenderness.

d. tachycardia.

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

3.5

www.aorn.org/CEPerioperative Nursing Care of

the Patient Undergoing BariatricRevision Surgery

This evaluation is used to determine the extent

to which this continuing education program

met your learning needs. Rate the items as

described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Describe types of bariatric surgery.

Low 1. 2. 3. 4. 5. High

2. Explain why people undergo bariatric revision

surgery. Low 1. 2. 3. 4. 5. High

3. Discuss complications that patients undergoing

bariatric revision surgery may experience.

Low 1. 2. 3. 4. 5. High

4. Identify safety precautions that perioperative nurses

should institute for patients undergoing bariatric re-

vision surgery. Low 1. 2. 3. 4. 5. High

CONTENT

5. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

6. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

7. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

� AORN, Inc, 2013

8. Will you change your practice as a result of reading

this article? (If yes, answer question #8A. If no,

answer question #8B.)

8A. How will you change your practice? (Select all that

apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: ________________________________

8B. If you will not change your practice as a result of

reading this article, why? (Select all that apply)

1. The content of the article is not relevant to my

practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other: ________________________________

9. Our accrediting body requires that we verify

the time you needed to complete the 3.5 con-

tinuing education contact hour (210-minute)

program:__________________________________

February 2013 Vol 97 No 2 � AORN Journal j 229