This presentation is on Management of Weight Regain after Bariatric Surgery.

1. Dr. Deep Goel, FACS (USA), FRCS (England)
Director
Department of Surgical Gastroenterology, Bariatric &
Minimal Access Surgery
Centre for Digestive and Liver Disease
BLK Super Specialty Hospital, New Delhi.
Post Bariatric Surgery
Weight Regain & Management

2. Disclosure
• Consultant and mentor- J & J
• Advisory consultant- Medtronics

3. Pubmed search
• Key words
- Bariatric surgery
- Gastric bypass
- Band
- Biliopancreatic diversion
- Reoperation
- Weight loss failure
- Weight regain
- Bariatric surgery failure

4. Morbid obesity
• Ailment of 21st century
• Chronic disease requiring life long treatment
• Surgical treatment is most durable
Ref : Ghanem M, Ranvier GF. Revisional bariatric surgery: A review
of the current recommendations.Saudi J Laparosc 2016;1:5-8

5. Defining failure??
“No clear cut guidelines are available to define
failure”
• Inadequate weight loss
• Weight regain
• Inadequate co morbidity resolution

6. Successful Weight Loss
• >50% of Excess weight loss at 18 months and
reasonable resolution of comorbidities
• Insufficient weight loss - < 50% EWL at 18
months

7. Weight Regain
• Weight gain after achievement of an initial successful
weight loss.
• An increase in weight >10 kg from Lowest weight
• An increase in BMI > 5 kg/m2 above lowest BMI
• >25% regain of EBMIL from the lowest weight.
Ref: international bariatric club.
www.ibcclub.org/re-sleeve-gastrectomy

8. Weight Regain
50% patients regain weight after 2 years
Average regain is 8% after reaching low point
10 year weight loss was present in >50%
Ref: Peter F. Rovito . www.bariatric-surgery-
source.com/weight-gain-after-gastric-bypass.2017

9. Procedure Failure & Revisional Surgery
• Whether procedure has really failed ?
• Who failed what ?
• Procedure failed the patient ?
• Patient failed the procedure ?
• Patient V/s surgeon's perspective.

10. Evaluation of a weight regain patient
↓
Go back to basics---be a physician

11. Evaluation of Weight Regain
Multidisciplinary assessment
Pre-bariatric weight
BMI
Excess weight loss
Weight loss prior to surgery

12. Evaluation of Weight Regain
• Pre operative counselling?
–Procedure
–Dietary
–Binge eating
–Grazing
–Alcohol/drug abuse
–Support group
• Psychological state
• Hormonal /metabolic imbalance( thyroid ,
adrenal)

13. Questions
• Volume of food intake ?
• Frequency of meals ?
• Type of food ?
• GERD ?
• New medications ?
• Sleep ?

14. Evaluation of Weight Regain
Anatomic problems are best diagnosed by
-Contrast upper GI series
-Upper G I endoscopy
-CT volumetry

15. Pouch Re-setting
• Way of returning your stomach back to the
size it was immediately after surgery
• Pouch resetting is non-invasive, safe, cheap,
and easy to carry out.
• Resetting period usually lasts for about ten
days

16. • 1st day- clear liquid diet
• 2-3 day- high protein liquid diet
• 4-5 day- pureed high protein
• 7-9 day- soft diet
• 10th day- regular diet
https://www.obesitycoverage.com/the-pouch-reset-losing-
weight-after-weight-regain

17. Revision Surgery - What To Do ?
Depends on
Patients anatomy
Primary procedure
Co-morbidities
Experience of surgeon

18. Laparoscopic adjustable band
• Loose  Recalibrate
• Slip/ Erosion Removal
• Removal  Sleeve gastrectomy
 LRYGB
 DS
single / staged

19. Band to Sleeve
• Single stage/ Staged
• Acceptable short term weight loss
• Overall complication – 12.2%
• Staple leak rate – 5.6%
• Staged procedure is associated with fewer leaks?
• Data is limited
Ref: Stroh C et al. Obes Surg. 2013.

20. Band to RYGB
• Medium term weight loss comparable to primary
RYGB
• Adverse events similar or slightly higher than
primary RYGB
• Complication rate 8.5%
Ref: Coblijn U K et al. Obes Surg. 2013

21. Band to BPD/DS
• Similar weight loss as primary BPD/DS
• Complication rates higher
Ref: Topart P et al. Surg Obes. Relat Dis.2007

22. Laparoscopic Sleeve Gastrectomy
5%-30% of sleeve patients had inadequate
weight loss or weight regain , requiring
additional procedure
Ref: Himpens J et al. Ann. Surg. 2010

23. Primary Dilatation
• Primary dilatation: incompletely dissected upper
posterior gastric pouch during the initial procedure
• Learning curve
• Difficult super obese cases
• Incomplete visualization of the left crus of the
diaphragm
Ref: M. Nedelcu et al. Surgery for Obesity
and Related Diseases.2015

24. Secondary dilatation
• Homogeneous dilated gastric tube
• Mechanism
–Natural history of LSG
–Use of a large calibration bougie
–Patient ’s eating habits
–Planned second procedure
Ref: M. Nedelcu et al. Surgery for Obesity and Related
Diseases .2015.

25. Post Sleeve Gastrectomy Options
• Band over sleeve
• Fundal dilatation  fundectomy
(primary dilation)
• Antral dilatation  Re sleeve or LRYGB
(secondary dilatation)
• Single anastomosis duodeno-ileal bypass
( SADI)

26. Sleeve to Re-sleeve
• Mean operating time was longer
• Post operative complications higher
• At 12 months EWL was 66% for resleeve as compared
to 77% for primary sleeve gastrectomy
• Achieve significant short term weight loss
• Slightly increased peri-operative complications
Ref: Rebibo L et al. Obes Surg. 2012

27. Sleeve to RYGB
Fourth International consensus Summit on
Sleeve Gastrectomy reported RYGB was prefered
option if second operation is required for weight
regain after Sleeve Gastrectomy
Ref: Gagner M et al. Obes Surg.2013

28. Sleeve to BPD/DS
• Better weight loss with BPD/DS at the expense of
increased risk of vitamin deficiencies
• No difference in short term complications
Ref: Homan J et al.Surg Obes relat Dis .2015

29. Post RYGB Options
Pouch dilatation
Endoscopic downsizing of the pouch
- arrest weight gain in short term
- minimal risk
Band over pouch
Resizing surgery
RYGB to Sleeve
Ref: Maleckas et al. Gland Surg. 2016

30. Post RYGB options
Stomal dilatation
• ROSE procedure( Restorative obesity surgery
endoscopic)
• Sclerosant injection
• Surgical correction
Ref: Maleckas et al. Gland Surg. 2016

31. Post RYGB Options
Distalization of the Roux limb
Distalization of the biliopancreatic limb
Resizing of the proximal bypass complex
Conversion to DS

32. Distalization
• Weight loss equal for alimentary limb or roux limb distalization
• Protein energy malnutrition more with biliopancreatic limb
Ref- Caruana J A et al.Surg Obesity Diseases.2015

33. Revision Surgery

34. RYGB to Banded RYGB
• Surgical refashioning of the gastric pouch
• Acceptable short term results
• Long term FU required
• Banded gastric bypass
• Weight loss variable
• Long term complication-17%
• Long term follow up studies required
Ref-Vijgen GH et al.Surg Obes Disease.2012

35. RYGB to BPD/DS
• Complex procedure
• Malnutrition risk high which limit this
procedure despite acceptable perioperative
complications
Ref- Keshishian A et al. Surg obesity diseases.2004

36. Revisional surgery
Technically challenging and associated with higher rate of adverse events
Desirable results if performed on the right patient in right timing
Clinical efficacy
• Remain unclear
• Evaluation of revisional surgery is limited
Guidelines and standards are unavailable
Multiple approaches have yielded variable results
Ref : Li JF et al .Surg Laparosc Endosc Percutan Tech 2014

37. Technical considerations
Anticipate thicker tissues
cartridge choice
High index of suspicion to diagnose complications
On table post-opeartive leak test
Low threshold for relaparoscopy

38. Our Results
• Total revisions- 23
• Primary bariatric surgery
• Our centre 08
• Other centre 15
• All revisions were staged procedures
• Band to sleeve 04
• Sleeve to RYGB 12
• Re sleeve 06
• Resizing of pouch apparatus 01

39. Conclusions
• Obesity is a chronic disease
• Surgery provides a powerful tool for
significant weightloss- not a cure
• Without proper care, the tool can lose its
effectiveness, leading to weight regain.

40. Conclusions
• Primary surgery has best chance
• Define failure?
• Do not jump to revise a procedure
• Proper evaluation

41. Conclusions
• Outcomes of revisional bariatric procedure are
inconsistently reported.
• Revisional procedures should be performed in
high volume tertiary care centres.
• Risks of revisional surgery are higher
• Long term studies are limited

43. GIS Team