Weight Regain After Previous Bariatric Surgery
Choose from:
- Weight regain after gastric banding
- Weight regain after sleeve gastrectomy
- Weight regain after gastric bypass
- Weight regain after stomach stapling
Weight Regain after Gastric Banding
If a gastric band has failed to produce significant and sustained weight loss, my preference is conversion to gastric bypass in appropriate patients. Sleeve gastrectomy is another option however in this context probably has a similar risk profile to gastric bypass but bypass has been studied in much more detail after banding than sleeve and may be more durable in the long term.
A video on robotic assisted conversion of band to bypass surgery can be found on the gastric bypass information page.
For further discussion on gastric band complications see my Comprehensive page on gastric band Problems.
Weight regain after Sleeve Gastrectomy
Sleeve gastrectomy is a relatively new procedure and long term follow-up research and data is not available. The extent to which weight loss from sleeve gastrectomy can be maintained over the years is still to be determined. What is clear is that weight regain can and does occur, just like the other procedures usually around 2-3 years post op.
Issues that might contribute to weight regain after sleeve gastrectomy:
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Stretching of the remaining stomach
It’s common that the size of the stomach after sleeve surgery can enlarge over the years. This may or may not be responsible for the fact that eating larger portions is definitely easier after a year or so post surgery. It is probably not the case that poor eating habits including overeating may lead to increased stretching of the stomach.
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Increase in hunger over time
Initially there is fairly powerful hunger suppression after sleeve gastrectomy surgery. This may be explained by removal of Ghrelin secreting cells from the part of the stomach which is resected. This hormonal effect may die off in some people over time as hunger levels often will increase somewhat over the passage of the years.
Possible Options for further intervention for weight regain after sleeve gastrectomy
- Surgical reduction of an enlarged sleeve
- Placing a ring or adjustable gastric band around the sleeve
- Conversion of sleeve gastrectomy to gastric bypass
- Conversion of sleeve gastrectomy to a malabsorption operation
- Endoscopic reduction of an enlarged sleeve with internal suturing
Surgical reduction of an enlarged sleeve
If the sleeve is significantly enlarged this could potentially improve restriction but is largely unstudied. The anatomy must be highly favourable for this option.
Placing a ring or adjustable gastric band around the sleeve
This option has been tried by some but there is very little data available. The ring (e.g. Minimizer ring) was not designed with the sleeve in mind but for the gastric bypass pouch. Adjustable gastric bands were also not designed for the sleeve and are hard to fix in place without the stomach fundus available.
Conversion of sleeve gastrectomy to gastric bypass (including banded bypass)
This is probably the most common option and usually results in further weight loss. The magnitude of further weight loss is usually moderate and all of the risks of bypass surgery are present. Because of anatomical issues with the remaining stomach, there may be very little overall stomach remaining after conversion of sleeve to bypass.
Conversion of sleeve gastrectomy to a malabsorption operation
This option entails dividing the first part of the duodenum beyond the stomach and allowing small bowel bypass to enforce calorie malabsorption. The standard option is called “Biliopancreatic Diversion with Duodenal Switch” and has been around for over 20 years. This operation has not been universally population due to occasional severe malnutritional problems and frequent smelly diarrhoea.
A new variant, called the SIPS procedure may transcend these issues by reducing the nutritional problems and the diarrhoea but maintaining excellent weight loss. This essentially entails bringing a loop of bowel up to the duodenum rather than a “Roux limb” as is the case with conventional Duodenal Switch
This new procedure can be offered through our clinic in appropriately selected cases.
Endoscopic reduction of an enlarged sleeve with internal suturing
This is an experimental procedure whereby the internal diameter of the sleeve may be reduced by internal sutures placed via a fibre optic endoscopic inserted through the mouth.
Weight regain after Gastric Bypass
Occasionally patients who have undergone gastric bypass surgery may regain weight over the years.
Issues that might contribute to weight regain after bypass:
- Gastrogastric fistula
- Pouch dilatation
- Stomal dilatation
- Small bowel hypertrophy or growth in size beyond the pouch
The above issues relate to a loss of the restrictive function of the upper part of the bypass.
If the weight regain is significant there are procedures which may allow restriction to be re-established and potentially getting things back on track. The possibilities are as follows:
- Reoperation with refashioning of the gastric pouch. This may also include complete redo of the small bowel to pouch join (upper anastomosis), possibly with replacing the entire small bowel limb (Roux limb). This is essentially redoing the entire operation again.
- Placing a small ring, such as Minimizer Ring around the pouch to re-create restriction. This is essentially converting the standard bypass into a banded bypass. Most literature on banded bypass indicates excellent long term outcomes and perhaps these can be recreated by placing the ring over a standard bypass
- Placing an adjustable gastric band (such as “Lap Band”) over the pouch to help maintain restriction
- Using the “Overstitch device” to reduce the pouch outlet diameter using a flexible fibre optic endoscope placed through the mouth into the stomach. More information on this procedure can be found here: http://apolloendo.com/procedures/outlet-pouch-reduction/.
The other alternative procedure is to convert the operation into a “Long Limb” bypass, effectively bypassing a large amount of small bowel to create malabsorption of calories.
Weight regain after Stomach Stapling
Stomach stapling (gastroplasty) has gone out of fashion now due to its high revision and reversal rate and the fact that it cannot be performed with keyhole or laparoscopic surgery. The procedure essentially involved creating a small pouch of stomach with a non-dividing stapling device and reinforcing the outlet with sutures or mesh or a ring of some sort.
Issues that might contribute to weight regain after stomach stapling
- Stretching of the remaining pouch
- Breakdown of the staples leading to pouch breakdown
- Maladaptive eating habits
Possible Options for further intervention for weight regain after stomach stapling
- Conversion to gastric bypass surgery
- Conversion to sleeve gastrectomy surgery
- Placing an adjustable gastric band over the pouch
- Re-stapling an enlarged or broken down pouch
- SIPS procedure??
Of these options, conversion to gastric bypass is the most commonly chosen. This has been well studied and will usually get things back on track in terms of weight loss. Sleeve gastrectomy may be another option but is much higher risk than performing sleeve without previous stapling. In my view it is probably best to end up with a bypass if that risk is to be taken. Placing a band around the pouch may have some benefit but there is a relatively high erosion rate (band can eat into the stomach). Re-stapling might be considered in high risk surgical patients who have an enlarged pouch.
The new SIPS procedure leaves the pouch alone and provides malabsorption of calories downstream by bypassing some of the small bowel just beyond the stomach. This is a relatively unstudied option.