To conclude this series of posts on our systematic review of weight regain following bariatric surgery, published in Obesity Surgery, we know turn to the ‘technical’ reasons for weight regain following Roux-en-Y gastric bypass (RYGB).
As with gastric banding and sleeve gastrectomy, enlargement of the gastric pouch can lead to weight regain.
In addition, the connection between the stomach and small intestine (gastrojejunostomy or stoma) can dilate allowing easier passage of food into the small intestine. According to the reports in the literature, stomal dilation is one of the
most frequently identified “technical” abnormalities in patients experiencing weight regain and has been shown to be independently associated with weight recidivism and to occur as early as 6 months following surgery.
Other studies have found a dilated gastric in almost one-third of RYGB patients experiencing weight regain.
Management option include the use of sclerotic agents, endoscopic suturing, as well as placement of a ring, band or mesh around the gastric pouch and/or anastomosis.
Another, albeit less frequent complication is the development of a gastro-gastric fistula between the gastric pouch and the excluded stomach. Although rare, such a fistula can can reduce the efficacy of the operation by allowing the passage of food directly into the bypassed intestine. The incidence of fistula has been reported to be preventable through proper surgical technique including the placement of an interposing loop of jejunum between the gastric pouch and remnant stomach.
In some cases, an unrecognised leak or abscess may also promote the formation of a GG fistula.
Thus, in summary, although most instances of weight regain are likely due to dietary, metabolic, or mental health factors, anatomical or “technical” complications (typical for each procedure) must be considered and explored in patients experiencing post-surgical weight regain (or failure to adequately lose weight post-surgery).
As with the initial assessment, diagnostic and management of post-surgical weight regain is best performed by a multi-disciplinary team that has expertise in the bariatric management.
Let me end this discussion by reminding readers that none of these issues speak against undergoing bariatric surgery when indicated. Fortunately, the outcomes in the vast majority of patients are substantially better than the alternative.
Karmali S, Brar B, Shi X, Sharma AM, de Gara C, & Birch DW (2013). Weight Recidivism Post-Bariatric Surgery: A Systematic Review. Obesity surgery PMID: 23996349