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Profesionales médicos

Complex bariatric surgery for high-risk patients and revision of past procedures

May 10, 2025

Bariatric surgery is an important option for people seeking effective, sustained weight loss. A 2024 study published in the International Journal of Surgery shows that the surgery can cure type 2 diabetes, especially with early referral and good follow-up care. Despite the increased demand for glucagon-like peptide-1 receptor agonists (GLP-1 RAs), surgical procedures will continue to play a vital role in medical weight loss.

The field of bariatric surgery also includes higher level care to address complex needs. This care is typically available only at specialized centers.

Omar M. Ghanem, M.D., is a metabolic surgeon at Mayo Clinic in Rochester, Minnesota, and leading expert in complex bariatric surgery. He offers advanced procedures, such as biliopancreatic diversion with duodenal switch (BPD/DS) and its modified version, single anastomosis duodenal-ileal bypass (SADI).

Dr. Ghanem is also a go-to when patients run out of options elsewhere. "Most often, that's because they had an unsuccessful procedure in the past or their risk is too high for bariatric surgery," he says.

Revisional bariatric surgery to improve outcomes and reduce complications

Bariatric surgery has a proven track record of success. But according to a 2024 study published in the Journal of Clinical Medicine, as many as 20% of patients require revision. The main reasons include insufficient weight loss, weight recurrence and complications such as:

Gastric fistulas.
Gastroesophageal reflux disease (GERD).
Hiatal hernias.
Leaks at the surgical connections.
Malnutrition.
Strictures, most often at the connection between the stomach and small intestine.
Anastomotic ulcers.

A Mayo Clinic study published in 2023 in the Journal of the American College of Surgeons demonstrates how effective revisional bariatric surgery can be. "The study included 53 patients experiencing malnutrition following primary bariatric surgery," says Dr. Ghanem. "Nearly 90% of patients received supplemental or total nutritional support before their corrective surgery. That percentage fell to 13% after surgery."

Revisional bariatric surgery accounts for about half of Dr. Ghanem's practice. Many of these patients have issues that make revision surgery risky elsewhere, such as heart failure, kidney disease or liver disease. Others are unable to reach their target weights. "No matter the problem, we always have options," he says.

Dr. Ghanem uses laparoscopic and robotic techniques to perform a wide range of revisional procedures, including:

Gastric bypass revision to correct for complications or weight recurrence.
Sleeve gastrectomy to gastric bypass.
Sleeve gastrectomy or gastric bypass to duodenal switch (BPD/DS or SADI).

Revision doesn't require surgery in all patients. "Our care team includes several bariatric endoscopists who provide revisional treatment. They might insert a stent or repair tissue endoscopically," says Dr. Ghanem.

In addition to collaborating with endoscopists, Dr. Ghanem works with expert radiologists skilled in detecting anatomical changes that can happen after bariatric surgery. His team also includes endocrinologists, psychologists, advanced practice professionals, residents and fellows. Together, they assess each patient to determine the best strategy.

Overcoming the risks of bariatric surgery

Safety concerns may prevent people who are older or who have severe obesity or other health conditions from having a bariatric procedure at some centers. "At Mayo Clinic, we routinely offer care for high-risk patients," says Dr. Ghanem.

Mayo Clinic has published one of the largest series of papers on bariatric surgery patients age 70 and older as well as other papers on patients with BMIs greater than 50 kg/m² and 70 kg/m². Data published in Surgery for Obesity and Related Diseases, Surgical Laparoscopy Endoscopy and Percutaneous Techniques, and Obesity Surgery show that bariatric surgery is safe for these patient categories, and patients are very satisfied with surgery.

Older age and obesity are also risk factors for paraesophageal (hiatal) hernia. Dr. Ghanem has helped establish the safety of bariatric surgery combined with hiatal hernia repair in people with severe obesity and older age. "We have performed this procedure on patients of all ages with excellent results."

Weight-loss surgery as bridge therapy

A high BMI may disqualify someone from having necessary surgery. Dr. Ghanem offers bariatric surgery as a path to weight loss for people awaiting procedures such as:

Abdominal wall hernia repair.
Hip or knee replacement.
Kidney, liver, heart or lung transplant.

For example, Mayo Clinic has established a fast track for patients who need to lose weight before orthopedic surgery. Usually, within about six months of bariatric surgery, patients have lost enough weight to undergo their orthopedic procedures. "We know that patients use bariatric surgery as a means to relieve their joint or hernia pain, so we do our best to get them in quickly," says Dr. Ghanem.

Enhancing the success of bariatric surgery

The main objectives of bariatric surgery are weight loss and improvement in chronic health conditions. Dr. Ghanem and his team developed a tool to predict diabetes outcomes after bariatric surgery. The tool estimates the chance of diabetes remission based on the percentage of body weight lost, while taking procedure choice into account.

Successful weight loss depends largely on the quality of follow-up care. After complex bariatric surgery, patients can choose to receive follow-up care at Mayo Clinic or closer to home.

"For patients who leave our care, we provide detailed instructions to the referring healthcare professional. We're also available as a resource as needed," says Dr. Ghanem. "Our goal is to ensure patients have the best chance of losing weight and improving their health and quality of life."

Mayo Clinic in Rochester, Minnesota, is recognized as an American College of Surgeons Level 1 Accredited Bariatric Center (the highest level) and meets Medicare's facility standards for bariatric surgery. Bariatric surgery accreditation promotes uniform standards of care, safety and quality improvement.