Post-Surgery Weight Regain: Roux-en-Y Gastric BypassFriday, September 20, 2013
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
Saturday, September 21, 2013
Is the stretching of the pouch or stoma something that just happens in a percentage of patients or something that can happen as a result of patient action? There is a lot of confusion and misinformation about this amongst bariatric patients in online forums.
Monday, September 23, 2013
Having seen and done endoscopy or UGI series on hundreds of patients with weight re-gain post RYGB, I have to say that I don’t buy the pouch dilation or stomal dilation argument. I think this falls into the category of “blame the patient” that Dr. Sharma argues so forcefully against (“Ms Jones, YOU stretched out your pouch by eating too much”). I think large pouches are likely made too large initially (since I often see enough gastric rugae in a large pouch that I doubt the “stretching” hypothesis). And the studies of “pouch reduction”, either endoscopically or surgically, are highly variable in weight loss outcome, with generally unimpressive results.
Almost every patient with weight re-gain has these in common: returning to high-carb processed foods (high glycemic index), no fitness regime, and many of the other emotional and psychological contributors Dr. Sharma’s other posts have enumerated. I think some surgeons (I say this as a surgeon) try to find surgical solutions to non-surgical problems. Rather than blaming the patient for their “failure”, we should be trying to design systems that facilitate patient success (long-term follow-up, mentorship, support networks, text message reminders, frequent program contact, etc.).