Weight Regain After Bariatric Surgery
Dennis Smith, M.D., F.A.C.S.
The question of weight regain is common with bariatric surgery patients. It can and does occur after all of the different types of operations. Some operations, like the Duodenal Switch, are generally regarded as being more resistant to weight regain than other bariatric operations, but no operations are immune to weight regain.
As bariatric surgery matures, and the number of post-operative patients many years out from surgery grows, this is a topic that deserves more attention, and must be discussed openly. There are some fundamental principles that patients can follow to help minimize weight regain, and it’s also important to understand what further options there are for patients experiencing weight regain, and what those options can and can’t do.
When a patient is regaining weight, it can be frightening and anxiety-inducing, and even embarrassing for the patient. They may feel they will be blamed for the regain, or that their surgeon or support group will shun them since they are not having great success. The patient may harbor fears they will return to the heavy condition they were so desperate to leave behind. A patient may also feel something might be done surgically to restore their weight loss – that something might have changed with their surgery that is causing them to be gaining weight as they are.
There are many things to look at in this kind of situation, and reoperating may not be helpful. Even if reoperation might make a small difference, it has to be compared to the risk of reoperating before it should be considered. While reoperation can sometimes be useful, it is most often the case that other modalities can slow, halt, and even reverse weight regain with much less risk.
As a surgeon, when I talk to a patient who is regaining weight, my first step is to reassure them that some regain is normal – usually a patient will lose their initial amount of weight over 1.5 to 2 years, and then will gain a little, before settling in to a comfortable weight. The most important thing is for them not to panic and abandon all their good behaviors, which might lead to even more regain.
We try to address weight regain from the beginning, before the patient has even had surgery, by educating patients on what strategies will be necessary for long-term maintenance. We try to help patients understand they must use the first couple of years, while they are losing weight so easily, to learn new behaviors and make new habits. They must get away from old triggers and learn new triggers so they can protect themselves in the future. Diligence and vigilance in careful eating must be learned, and put into practice every hour of every day. In addition to learning new eating habits, patients must incorporate exercise into their lives in a regular and permanent way, and surround themselves with people who will help enable them to succeed with these things in the long-term.
Sometimes patients are losing so easily and so well they might feel they don’t have to adhere to some of the healthy living strategies we advocate. But just because they’ve had bariatric surgery doesn’t mean they can continue to live in an unhealthy way and expect everything to be okay. The whole idea with bariatric surgery is that the operation is just part of the solution – the rest is changing the way life is lived. If weight regain shows up as a problem, then adopting these strategies is imperative, including smart eating and exercise, as well as ongoing support and follow-up to help patients stay on the right path.
One of the keys for success after any bariatric operation is to avoid stretching the pouch. The restriction associated with these operations is used best if it is preserved through careful eating. Roux-en-Y Gastric Bypass and Lap-Band patients must always be conscious of this when eating. Repeated overeating over time will result in stretching of the pouch and this can contribute to weight regain. With the Sleeve Gastrectomy and the DS, we also try to have people restrict how much they put on their plate, with the expectation that limiting the amount eaten at a given meal will help patients avoid stretching their stomach pouch.
We also try to educate patients on healthy nutrition habits they can incorporate into their lives for life. Eating the wrong things, grazing, or drinking calories can also contribute to weight regain, and we try to prepare patients to avoid these things after surgery.
Once a patient is found to be regaining after their initial weight loss, we try to help them use the anatomical changes they have to battle back. Whatever their weight situation, they still have a smaller stomach, and with the DS and the RNY they have a bowel that is configured to give them some malabsorption or maldigestion. Using a patient’s anatomy to their best advantage is the first weapon against weight regain.
Examining eating habits will sometimes help identify an area where a patient is sabotaging their success. It’s important to understand that no operation is able to withstand poor eating habits – truly all of the bariatric operations can be defeated if eating habits are poor enough. So, a resolute and aggressive discipline in eating habits, which is much easier after surgery than before, helps maximize the effect of the operation. Small measured meals every few hours, keeping a food diary, targeting protein rich foods, avoiding processed starches and sugars, avoiding grazing and avoidance of liquid calories are among the eating strategies we employ.
Sometimes revisiting psychological issues can be helpful in identifying areas where maintenance of weight is being adversely affected. If there is emotional or stress eating going on, these triggers should be addressed. There can be new issues that arise with relationships, etc., that may be causing problems, and these can be evaluated by counselors who are familiar with these problems.
Exercise is an extremely important element of maintaining weight loss and avoiding regain. Sustained elevation of the metabolism, protection against reduction of the metabolic rate, and preservation of muscle mass and bone strength are all byproducts of regular exercise, and its importance cannot be understated. Regular exercise also keeps energy levels high and affects ones overall feeling of health and well-being, and this can favorably affect eating behaviors also.
Anatomical changes do happen, and can in some ways contribute to regain. We know the stomach pouch does stretch and enlarge over time, but much of the understanding of how much the stomach stretches is based on data that came from years ago, when stomach pouches were generally made larger than they have been for the last several years. For example, most DS surgeons these days make stomach pouches in the 60 - 100cc range, as opposed to up to 200cc or more years ago. RNY pouches are also made smaller nowadays than they were many years ago. Even Lap-Bands are generally placed higher on the stomach than when they were originally done, thus creating a smaller pouch. A smaller stomach pouch will have less capacity to stretch than one that was first constructed at a larger volume, and we expect that with smaller stomach pouches, we’ll have less regain due to overstretched stomachs.
With the Duodenal Switch, some of a patient’s weight loss comes from malabsorption of fat in the “common channel”, where food and the digestive juices are allowed to mix in the last 75 – 100 cm of the small bowel. This portion of the bowel also can and does change over time. We know from studies of short bowel syndrome patients that the small bowel can adapt over a few years such that it is able to absorb more efficiently. We see in our patients who have fat-soluble vitamin deficiencies that they will often improve their absorption over the first couple of years. We expect the bowel’s ability to absorb fat improves over time, but we also expect it is limited in how much it can improve.
The changes in anatomy we’ve talked about here are both limited in how much they can occur, and we also have to put them in perspective. Some of the change we see accounts for part of the reason a patient stops losing weight after bariatric surgery. It would have to be a very dramatic change to not only stop the weight loss but also cause significant weight regain. Each patient’s situation is a unique entity, and if your surgeon determines there is an anatomical situation that seems to be causing significant regain, then surgery can be considered, with some cautionary caveats.
Revision of bariatric operations for inadequate weight loss is a somewhat controversial topic. With any revision of a bariatric procedure, there are some basic ideas that must be kept in mind. First is that there is risk involved, and it is a significantly greater risk when it’s a revision than when it’s the first time around. Another consideration is the cost – many insurance companies don’t cover a second bariatric operation, although each policy is different. A third and very important consideration is that the body is not easily “fooled” twice. In other words, once the body has been given a restrictive operation, it will not be as responsive to yet another restrictive operation. So, for example, re-operating on a Roux-en-Y Gastric Bypass to reduce the size of the gastric pouch generally gives less than spectacular results in terms of re-inducing weight loss.
With the DS, the approach to revising for inadequate weight loss would be to either reduce the size of the stomach pouch, or to shorten the length of the common channel, whichever seems more likely to be the culprit in inducing weight regain. There is some data that seems to support revision of the stomach pouch in some situations, but other data that seems to indicate the weight loss induced by this type of revision is minimal. Revising the common channel to be shorter is generally not advised, since it often just makes side effects of loose bowel movements and fat malabsorption worse rather than making weight loss dramatically better. Again, since the risk is substantially higher with a surgical revision than with the initial DS operation, the projected benefit has to be significant in order to justify the risk.
A revision can be done with an open or a laparoscopic operation, or it can be done with one of the newer trans-oral endoscopic (incisionless) techniques. These methods can reduce the size of the stomach pouch after bariatric operations. There are several of these new technologies being developed, and they may allow a modest improvement in weight loss or control of reflux after bariatric surgery with much less risk than with a surgical revision. The effect of a pouch revision with any bariatric operation is usually a very modest weight loss by any method, and the projected benefit versus the risk must be assessed for each individual patient’s situation.
Weight regain can be understandably troubling to a weight loss surgery patient, but there are ways of fighting back without revisional surgery. If weight regain is excessive, then non-surgical areas should be fully explored before entertaining any thoughts of reoperation. Fortunately, weight regain is usually limited, and can usually be well-controlled with non-surgical strategies.