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
When a surgeon is evaluating the choices available for a revision procedure
the single most important consideration is the first WLS operation:
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.
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.
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.
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 Author
Milton 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.