Weight Regain No Shame ZoneMay 24, 2021
Weight Regain No Shame Zone: The Scope of the Problem
The past three decades have seen an explosion in bariatric surgery, not only in terms of technical advancements, safety, and effectiveness but also with the number of surgeries that are now performed.
Current figures from the American Society of Metabolic and Bariatric Surgery (ASMBS) reveal over 220,000 bariatric procedures are now done each year in the United States – more than a 10-fold increase since the early 1990s.
This data alone is a testament to the role that bariatric surgery has established in the multidisciplinary management of the obesity epidemic. It is well-accepted that operations including sleeve gastrectomy and gastric bypass engage mechanical and hormonal mechanisms for weight loss that diet and exercise alone often cannot.
Patients who qualify for and undergo surgery for weight loss will see dramatic improvements in body weight and the associated cardiovascular and metabolic problems associated with obesity, including diabetes, high blood pressure, and high cholesterol.
Weight Regain No Shame
In spite of these successes, weight regained after bariatric surgery remains a frustrating reality for nearly one in four patients.
The reasons for weight regain are not always well-understood, and addressing this problem is challenging for patients and bariatric specialists alike. One of the reasons for this difficulty is that there is no currently agreed-upon definition for weight regain after bariatric surgery.
The research community will often define weight regain as a failure to maintain a percentage of excess weight loss of 40-50%, depending on the study.
However, a more practical definition of weight regain may simply be an inability to maintain weight loss along with the improvements initially enjoyed in the patient’s quality of life and associated medical conditions.
Another cause for frustration has been that the search for patient characteristics before surgery that might predict weight regain afterward has been elusive: Older age, male gender, and a history of diabetes may have bad influences on outcomes with surgery, but the effect is small and not likely to account for the whole story. Certainly, patients who start in the highest weight ranges represent an at-risk population for weight regain.
You’ve Gained Back the Weight After Surgery, Now What?
Be proactive about weight regain and meet with your bariatric surgeon. If you're concerned about reaching out for information on your weight regain, keep in mind "weight regain no shame" is the mindset to have.
The first step in evaluating a patient who has experienced weight regain is, as with so much of bariatrics, to get a full picture of the patient’s progress after the initial operation.
For the surgeon, it is obviously crucial to ensure that there is no anatomic abnormality or complication of the patient’s primary weight loss surgery. A good working relationship with a bariatric surgeon will ensure that patients with weight regain undergo the necessary diagnostic testing, which often includes an upper GI study and endoscopy.
If no technical or anatomic problem is discovered, additional questions will demand attention: How adherent has the patient been to bariatric follow-up, dietary guidelines, and exercise recommendations? Has there been sufficient follow-up with the bariatric dietitian?
While these hallmarks of bariatric care may sound routine, they require a significant investment of time and resources that are limited. In an era of accelerated telemedicine and web-based technology that has been ushered in by the COVID-19 pandemic, many behavioral and lifestyle resources once confined to the clinic or support group settings can now be readily deployed to patients through this medium.
Finally, all patients should have their medications reviewed, as many drugs used for the treatment of a variety of conditions (including diabetes medicines, blood pressure medicines, antidepressants, and anti-seizure medicines) have the potential to contribute to weight gain, and in many cases there are alternatives.
Surgery for Weight Regain After a Sleeve Gastrectomy
The sleeve gastrectomy procedure now accounts for well over half of all bariatric operations performed in the U.S. It is important to be familiar with the options that exist for reoperation in the face of inadequate weight loss or weight regain.
Diagnostic testing may reveal that the upper part of the stomach, known as the fundus, has become enlarged over time. Patients with this abnormality often have severe gastro-esophageal reflux (GERD) disease. Often, however, there is no abnormal anatomy discovered, and an exhaustive multidisciplinary effort that successfully addresses a patient’s dietary and lifestyle factors simply fails to achieve weight loss.
When this is the case, the two key operations most commonly performed are a conversion of the Sleeve Gastrectomy to a Roux-en-Y gastric bypass (RYGB) or a Bilio-Pancreatic Diversion with Duodenal Switch (BPD-DS, or simply “duodenal switch”).
Patients who have experienced weight regain with a reflux disease after a Sleeve Gastrectomy stand to benefit from undergoing a RYGB. During this procedure, the top of the stomach is fashioned into a small pouch that is connected to the intestine farther down the gastrointestinal tract (hence, “bypass”).
Food travels from the small stomach pouch directly into this segment of the intestine and avoids coming into contact with the many feet of the intestine that lie upstream; the ability to absorb nutrients and replenish calories is thus limited. A second connection is made between the intestine carrying ingested food and the intestine carrying digestive juices from the liver and pancreas to maintain the ability to process foods and avoid severe malnutrition. The bottom portion of the stomach remains in place but does not participate in digestion.
By eliminating much of the stomach from the newly-arranged gastrointestinal tract, the esophagus no longer comes into contact with acidic stomach contents and reflux symptoms are improved.
For patients without reflux disease, and in particular, for patients who may not have experienced satisfactory weight loss after a sleeve gastrectomy, to begin with, the duodenal switch is another option. A new form of the operation, which has been refined since its origin in the 1980s, is known as “SIPS” or “SADI,” which stands for Stomach Intestinal Pylorus Sparing surgery or Single Anastomosis Duodeno-Ileostomy, respectively.
These operations differ from the original duodenal switch in that only one anastomosis is made, thereby reducing the complexity of the procedure as well as minimizing long-term nutritional deficits.
In a SIPS/SADI after a sleeve gastrectomy, the stomach is left alone. The portion of the intestine that receives food from the stomach (the duodenum), however, is re-routed to a point close to the end of the small intestine itself.
As with a RYGB, a long stretch of the small intestine is kept out of contact with ingested foods. Several well-designed studies have suggested that more weight can potentially be lost by converting a sleeve gastrectomy to SIPS/SADI than gastric bypass.
Nevertheless, patients undergoing a SIPS/SADI may still experience nutritional deficiencies that require closer and more frequent attention. Furthermore, unlike a gastric bypass, a SIPS/SADI will not likely address reflux symptoms and the potential for additional harm to the lower esophagus.
Weight Regain No Shame Zone - Final Thoughts
Undergoing surgery for the treatment of obesity and related cardiovascular and metabolic diseases is a life-long commitment. Don’t fall off the radar! You owe it to your present and future self.
You need to have a home for your bariatric medical, surgical, counseling, dietary, and lifestyle needs. It is our responsibility as specialists in the field to make sure that you reap the full benefits of the commitment you have made to a healthier future.
- Dijkhorst PJ, Boerboom AB, Janssen IMC, Swank DJ, Wiezer RMJ, Hazebroek EJ, Berends FJ, Aarts EO. Failed Sleeve Gastrectomy: Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass? A Multicenter Cohort Study. Obes Surg. 2018 Dec;28(12):3834-3842. doi: 10.1007/s11695-018-3429-z. PMID: 30066245; PMCID: PMC6223754.
- Carmeli I, Golomb I, Sadot E, Kashtan H, Keidar A. Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm. Surg Obes Relat Dis. 2015 Jan-Feb;11(1):79-85. doi: 10.1016/j.soard.2014.04.012. Epub 2014 Apr 24. PMID: 25304833.
- Shukla AP, He D, Saunders KH, Andrew C, Aronne LJ. Current concepts in management of weight regain following bariatric surgery. Expert Rev Endocrinol Metab. 2018 Mar;13(2):67-76. doi: 10.1080/17446651.2018.1447922. Epub 2018 Mar 8. PMID: 30058859.
ABOUT THE AUTHORDr. Gregory Dakin is an Associate Professor of Surgery and an Associate Attending Surgeon at New York-Presbyterian/Weill Cornell Medical Center in New York, NY. He completed both general surgery training and specialty training in minimally invasive surgery. Dr. Dakin is certified by the American Board of Surgery and specializes in laparoscopic abdominal surgery.
ABOUT THE AUTHORDr. James Senturk is a fellow in advanced gastrointestinal and minimally invasive surgery in the Division of Advanced GI and Metabolic Surgery at New York Presbyterian/Weill Cornell Medical Center. He attended medical school at Mount Sinai and completed his residency in surgery at Brigham and Women’s Hospital in Boston, MA.