Understanding Post-Op Weight Regain & Revision SurgeryMarch 11, 2016
Weight loss surgery has been helping patients lose weight and improve their health for many years. Although the surgery and subsequent weight loss have dramatically improved the lives of many, approximately 15% of patients regain much of their preoperative weight. For patients that have experienced weight regain, there are surgical options available.
Ways to Avoid Post-Op Weight Regain
It would be misleading and a disservice to patients not to explain the causes of weight regain and the ways to avoid them. Gain and regain likely occur for the same list of reasons.
Current thinking is that we have an inherited susceptibility for obesity, with some of us having very little susceptibility and some of us much more. In both cases, consistent unhealthy food choices, at some point, produce major internal changes.
Gradually (and sometimes not so gradually) the body alters energy management. Think of it like this "I keep getting all these excess calories so they must be important". As a result, instead of burning off excess calories as heat, or not absorbing them in the first place, the body starts storing them as fat.
To make matters worse, the body “decides” that gained weight should be protected from loss, so it becomes easy to gain but much more difficult to lose. Fat cells distend to their limit, then will break and the ruptured products set up a diffuse internal inflammatory process that damages all systems and organs. Fortunately for us, "metabolic" operations such as the Vertical Sleeve Gastrectomy and the RNY Gastric Bypass appear to reboot a person’s metabolism. In hours, hunger decreases, food preferences change, weight loss is no longer defended against, and the once lean person inside the body starts to reappear.
It is not known how complete and the duration that the reboot will be. Exercise appears to be necessary if a reboot is to occur in the muscle. Clinical observations suggest that it takes considerably less to restart weight gain than it did to induce obesity in the first place.
Nothing is as important to the person who has had weight loss surgery than a consistent well-informed adherence to a proper diet that consists of healthy food choices. Exercise is a close second. Both of these apply whether or not there is a problem with weight regain.
Cortisone, progesterone, and drugs that affect anxiety and mood may initiate and continue to drive weight gain. Alternatively, drugs that depress appetite as well as some that treat diabetes may slow or reverse regain.
Now, let's review the options that are commonly considered when the initial WLS procedure is seen to have failed.
The Differences in Revision Surgery
Depending on the response to managing diet, exercise, and drugs, revising the original operation may not be needed. However, for many people, lesser therapies are insufficient and a Revision is an option. Another trip to the operating room is the best, and often, the only effective choice. It is an unfortunate fact that insurance companies’ rules and the extent of coverage often determine the available options. It is wise to decide first on the best surgical option, the next best, and so on and then evaluate how matters will be affected by the insurance companies.
When a surgeon is evaluating the choices available for a revision procedure the single most important consideration is the first WLS operation:
- Lap-Band. The Band operation has been widely done around the world because it is the safest of the weight loss procedures. In my experience, it works very well for about one-third of patients. Another one-third obtain a modest effect over a long period of time. The remaining one-third of patients either gain weight in spite of the Band or have it removed for complications. Patients that have done well with the Band generally wouldn’t have anything else. If a “slip” occurs, or the tubing cracks and leaks, replacing the Band is the preferred choice. For the larger group of patients who are less enthusiastic about the Band, there are a number of options. The Band can be removed and the anatomy configured to create a Vertical Sleeve Gastrectomy, a Gastric Bypass, or one of the "Switch" operations. Sometimes a Sleeve or imbrication is created below the Band. There is no single best choice, so the revision needs to be individualized depending on the patient and the surgeon. A rare patient who has sufficiently internalized the discipline imposed by the Band can get by with simply removing the Band.
- Vertical Sleeve Gastrectomy. One very popular addition to the weight loss surgery procedures, and now one of the most commonly done procedures in the United States, is the Vertical Sleeve Gastrectomy. The Sleeve was introduced about 10 years ago and has done much to improve weight loss surgery. Initially, it was seen as an improvement on the RNY Gastric Bypass because weight loss was similar while long-term complications were fewer. The simplicity of execution and superior weight loss of the Sleeve also resulted in it nearly replacing the Adjustable Band (Lap-Band). If the Sleeve has enlarged over time and food consumption has increased, weight regain may be treated by simply reducing the Sleeve to the original size. For extra effect but with added risk, this may be combined with one of the "Switch" procedures. Conversion to a Gastric Bypass is another option which is particularly attractive if heartburn or poor esophageal motility is an important consideration. Selective imbrication of the Sleeve is also done.
- RNY Gastric Bypass (RNY). The RNY operation was, and still is, the procedure against which others are compared for diabetes control and post-operative weight loss. Nevertheless, a resurgence of appetite and subsequent weight regain appears to affect a substantial number of patients over time. Rarely, following Gastric Bypass an abnormal reconnection occurs between the pouch and the bypassed portion of the stomach. Weight regain is one consequence. Repair of the leak and partial removal of the bypassed stomach usually restores the effectiveness of the original bypass. More commonly, the pouch enlarges or the opening between the pouch and intestine dilates. The pouch or the opening may be tightened up either surgically or endoscopically. A sense of fullness may be restored but tends to lessen over time as the tissues stretch and adapt to the volume of food. An option is to place an Adjustable Band around the pouch (“Band Over Bypass”). Volume and tightness can be altered to fit the patient’s needs, however, a metabolic reboot similar to that seen with Gastric Bypass does not occur. For this reason, some surgeons are reconnecting the Gastric Bypass and adding a Switch or similar malabsorptive procedure. The price is considerably more because it is a complex surgery. The need for compliance with vitamin and mineral supplementation is important. For some patients with this revision, protein supplementation may also be necessary. This may be the safest, and best option because the patient will likely experience the reboot.
- Duodenal Switch, Biliopancreatic Diversions, and similar procedures. These operations, (such as the DS) are both the most effective and complex of the weight loss procedures performed. All of them work, in part, by impairing caloric absorption and, to a greater or lesser extent, the absorption of vital nutrients which must be supplemented for a lifetime after surgery. Patients who regain after one of these procedures are rarely candidates for further weight loss surgery procedures or revisional surgeries.
Remember that your surgeon is there to help you make decisions and manage your post-op success. Keeping in touch with your surgeon and his or her team is an important part of your weight loss journey.
ABOUT THE AUTHORMilton Owens has performed approximately 8,000 weight loss surgeries, including gastric bypass, gastric sleeve, and adjustable gastric banding procedures. He was the first in Southern California performing sleeve gastrectomy. His “Inverted Corner Gastric Sleeve” technique, developed to minimize heartburn and prevent leaks has been published in the premier journal for weight loss: SOARD. His experience led him to expertise in complex revision surgeries, care for seniors and other high risk patients.