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31. Evaluation and Treatment of the Patient Who Is Regaining Weight
Keywords
Morbid obesityBariatric surgeryGastric bypassSleeve gastrectomyWeight regainWeight recidivismInsufficient weight lossRevisional surgeryIntroduction
Obesity is a significant worldwide problem. This emerging healthcare epidemic affects millions of people in the United States [1]. Moreover, increasing BMI is associated with greater comorbidity burden affecting a patient’s quality of life and results in greater cost burden to the nation [2, 3]. A similar pattern is seen all over the world in both industrialized and developing countries [4]. Likewise, bariatric surgery offers the best long-term outcomes regarding weight loss and comorbidities resolution [5]. Accordingly, the number of bariatric operations has increased during recent years. According to the last IFSO worldwide survey, 685.874 operations were performed during 2016, of which 92.6% were primary and the rest were revisional operations [6]. Sleeve gastrectomy (SG) was the most performed operation worldwide (53.6%), followed by the Roux-en-Y gastric bypass (RYGB) (30.1%), and one-anastomosis gastric bypass (OAGB) (4.8%) [6].
Morbidity and mortality related to bariatric procedures have improved due to developments in technology and training of surgeons. Currently, mortality is less than 1%, and morbidity is under 10% [7–9]. However, one long-term concern is weight regain and may represent one of the most important long-term considerations after bariatric surgery [10]. Moreover, weight regain can be associated with either development or return of previously resolved or well-controlled obese-related comorbidities such as type 2 diabetes [11]. Weight regain has been described as the most common reason for revisional surgery accounting for 52.2% of these operations [12]. In addition, the reported incidences vary depending on the primary operation and follow-up. Braghetto et al. reported 40% of patients regaining weight after SG at 5-year follow-up, [13] and Torquati et al. reported a weight regain of 17.1% for RYGB at 2-year follow-up [14].
Weight recidivism is recognized as a significant problem, but there is no consensus now on the correct nomenclature. Some terms that are in common use include weight regain, weight recidivism, and insufficient weight loss. Generally, there is agreement in the bariatric community that obesity is a chronic disease, that weight regain may be related to multiple etiologies, and a multifactorial approach to its treatment, is critical. Options for treatment include behavioral modifications, pharmacological intervention, endoscopic revision, and surgical operations. Surgical revisional operations are deemed safe but are associated with statistically significant higher morbidity and mortality that is acceptable from a clinical perspective [15].
This chapter describes the current definitions of weight recidivism in RYGB and LSG, initial diagnosis and management, and up-to-date interventions. Different endoscopic and surgical interventions with their respective outcomes, technical tips and pitfalls, and their outcomes are explored.
Definition of Weight Regain After Bariatric Surgery
Currently, there is no consensus to report success in bariatric surgery. Different authors have used various methods to describe success of weight loss operations in the literature. In order to avoid misinterpretation, ASMBS has proposed a standardization of terms and calculations to report surgical weight-related outcomes [16]. These definitions are important in understanding the literature on weight regain. However, success of weight loss after reoperations is reported variously as either from the time of the index operation or from the time of revision. It is also clear that body mass index (BMI) is a poor indicator of the percent of body fat since it does not capture information on the fat mass in different body sites [17]. Hence, BMI and those values that use BMI for their calculation as percentage of the excess of weight loss (%EWL) may not be the best way to describe weight regain. For this reason, percentage of total weight loss (%TWL) after the primary operation and after revision may be the best indicator of body mass loss after bariatric surgery and for description of weight regain. Historically, a successful bariatric operation was defined by Brolin as loss of 50% EWL or more [18], and this criterion has been used by several authors to publish their outcomes. Success can also be described using Reinhold’s criteria [19], which were modified by Christou [20], in which a good outcome is defined as postoperative BMI of less than 35 kg/m2 and excellent when it is less than 30 kg/m2.
Weight regain also needs to be differentiated from the failure to lose adequate weight after a primary bariatric operation. The most common definition of weight regain is an increase of body weight of more than 10 kg from the nadir [21], although other definitions can be found in the literature. Weight regain rates for SG have been reported as high as 75.6% at 6 years follow-up [22], but unfortunately, these authors did not report the definition that was used for this purpose. Recently, Casella et al. reported their SG outcomes at 10 years [23] and found that out of 182 patients, 10.4% had weight regain using the definition mentioned. Lauti et al. analyzed a cohort of 96 patients and applied 6 different types of definition of weight regain [24]. Using these different definitions, the proportion of patients with weight regain ranged from 9% to 91%, depending on the definition used. These data show that reports can vary due to a lack of standardization of nomenclature. Weight regain after RYGB operations over long-term follow-up has also been reported [25]. Christou et al. [20] reported a failure rate of 20.4 and 34.9% at 10 years based on final BMI ≥35 kg/m2 for morbidly obese and BMI ≥40 kg/m2 for super obese, respectively. Cooper et al. [26] reported a 23% mean weight regain from nadir over an average of 7 years of follow-up among 276 respondents, via a self-administered questionnaire. Recently, Kothari et al. published their 10-year results after RYGB [27]. Patients had a mean 79% EWL at 18 months, but that number decreased to 50% at 12-year follow-up [27].
Factors Involved in Weight Regain
Many etiologies have been proposed to explain weight regain. The success of treatment of obesity lies in multiple factors, each playing an important role. There must be a perfect balance between the characteristics of the patient, management by the multidisciplinary team, and the chosen surgical technique. Currently, there is no perfect way to do this, and surgeons and patients often choose the simplest operation that is associated with the least likelihood of complications. This accounted for the previous popularity of the LAGB and the current rise of the sleeve gastrectomy. For these reasons, the causes for weight loss failure or weight regain are grouped according to those dependent on the patient, the multidisciplinary team, and the surgery. The multidisciplinary management should aim their efforts in maximizing weight loss while preventing nutritional problems.
Patients Demographic
Preoperative BMI is one of the strongest predictors of weight loss after bariatric surgery, and higher initial BMI (>60) predicts inadequate weight loss at 12 months [28]. Younger patients are more likely to experience significant weight regain. In a study of 244 previously successful patients, younger patients were more likely to experience significant weight regain both at 96 and 120 months of follow-up [29]. Multivariate analysis revealed that younger age was a significant predictor of weight regain even after adjusting for duration after RYGB [14]. Conversely, some authors have reported that older age (>60) predict poor weight loss [28]. Recently, Keith Jr. et al. found that white race, male sex, and higher socioeconomic status were risk factors for weight regain after surgery [30]. Interestingly, patients who waited longer than 18 months for surgery and had preoperative weight gain also had inadequate weight loss [28].
Behavioral Evaluation
The adoption of preoperative behavioral evaluation is important when deciding on bariatric surgery. Patients who lack compliance with follow-up appointments after surgery and increase their calorie intake are at increased risk of weight regain [31]. Patients must clearly understand the objectives of the surgery and agree on expectations in conjunction with the surgeon and the multidisciplinary team. Detecting and treating eating disorders before surgery are mandatory because it can influence weight loss and subsequent weight regain. Kofman et al. described patients that have eating disturbances and uncontrolled desire to eat are more predisposed to regain weight after their surgeries [32, 33]. Rutledge et al. evaluated 60 patients who underwent a RYGB [34] and found that two or more psychiatric disorders were associated with less weight loss and more weight regain at 1 year after surgery.
Biological Factors
After bariatric surgery hormonal patterns change drastically, and that may explain many of surgery’s effects and benefits. Moreover, hormonal pathways have been suggested to explain poor weight loss and weight regain [35]. Santo et al. described a study in which they found that patients who had weight regain also had less elevation of GIP and GLP-1 levels after meals [36], and this was predictable on preoperative evaluation. Tamboli et al. described that high preoperative levels of ghrelin might identify patients who have weight regain after surgery [37]. However, these findings have not been corroborated by other authors [38].
Another interesting argument is the set point theory that postulates that the body will defend a predetermined set point to preserve body mass and function. A disproportionate reduction of fat-free mass may suppress the resting metabolic rate in order to preserve muscle mass. This translates in less efficient calorie consumption and decrease in caloric requirements, thus promoting weight gain [39].
Multidisciplinary Team
Compliance with follow-up positively influences weight loss after bariatric surgery [40]. Nutritional and psychological counseling after bariatric surgery is mandatory. The team must arrange the postoperative visits according to the resources available locally. It is important for the patient to understand that after bariatric surgery, lack of nutritional counseling and compliance during postoperative status will determine poor outcomes [41]. Early detection of weight regain can be appropriately managed by the dietary team in order to avoid future weight issues [42]. Psychological evaluation for bariatric patients must be individualized [43]. Closer follow-up by the mental health team is mandatory in order to treat preoperative conditions or detect new psychological disorders that might affect outcomes [44]. In addition, physical therapy after bariatric surgery is important [45]. Exercise can improve a patient’s metabolic profile and provide benefits in addition to the metabolic effects of bariatric surgery [46] and can help maintain weight and avoid future weight regain [47].
Technical Factors
Several factors related to the primary bariatric operation can be potential reasons for weight recidivism. These anatomical changes can arise from inappropriate surgical technique or be an evolution in the natural history of the postoperative course. Several authors have proposed mechanisms to explain weight regain after bariatric surgery [21, 35] and are presented separately for RYGB and SG.
Factors Associated for RYGB
Weight regain has been attributed to certain anatomical factors such as the size of gastrojejunal (G-J) stoma, size of the pouch, and gastrogastric (G-G) fistula. Previously, the Cleveland clinic group defined an enlarged stoma as one that measured more than 2 cm, and the pouch was considered to be enlarged or dilated if it was >6 cm in length or >5-cm-wide [48]. Later, Haneghan et al. analyzed a population for weight regain patients and found that a dilated stoma (>2 cm) was an independent predictor for weight regain but could not find any statistical difference related to pouch dimensions [49]. Abu Dayyeh et al. showed that stoma diameter was significantly associated with weight regain after RYGB. At 5 years after the RYGB, each 10-mm dilatation in the G-J stoma diameter was associated with a substantial weight regain [50].
The results regarding pouch size have been unclear. Roberts et al. studied 320 patients who underwent a RYGB at Yale University Hospital and found that pouch size has a direct effect on weight loss at 6 and 12 months after surgery [51]. However, other experiences have not found any relation between pouch size and weight regain [49, 52]. In addition, gastrogastric (G-G) fistula must be ruled out as a cause of weight regain. The restrictive and hormonal effect of the gastric pouch can be diminished if there is a communication with the excluded stomach. If a G-G fistula is found during investigations for weight regain, revisional surgery to eliminate the G-G fistula may be helpful.
Factors Associated for SG
SG is the most commonly performed procedure in the world because of excellent weight loss, resolution of comorbidities, and technical simplicity. However, SG has technical steps that must be followed to avoid poor weight loss and decreased comorbidity resolution, as well as lower morbidity and mortality. Several anatomical factors have been described as a cause for weight regain after SG [21]. The volume of the resected stomach has been suggested as a predictor of failure or weight regain [53]. Bougie size is directly related to the amount of stomach that is resected during a SG . However, Parikh et al. did not find any association between smaller bougie size and better weight loss [54], and small bougie size has been described as a risk factor for complications such as more nausea, vomiting, strictures, and perhaps reflux symptoms [55]. Typical bougie size ranges from 32 to 40 Fr. Experts tend to use larger bougie size. It is more important to perform an appropriate resection of the gastric fundus to avoid its dilatation and subsequent decrease in the restrictive effect of the SG than simply focus on the bougie size [56].
Nonetheless, Braghetto et al. could not find a direct relation between sleeve dilatation and weight regain at 5-year follow-up [13]. Large antral remnant has also been described as a risk factor for weight regain [57, 58]. Recently, a meta-analysis showed that antral resection has better weight loss compared with patients with antral preservation, without differences in complications rate [59]. Nevertheless, the impact of the antral remnant in long-term weight loss and or weight regain is unknown and needs further investigation.
Predictors for Weight Regain
Patients must be evaluated carefully starting at their first postoperative visit to identify those who are at risk of suffering weight failure. For patients with weight regain, anatomical factors described in the previous section must be evaluated to identify a cause for weight gain as a G-G fistula or a dilated pouch or stoma.
Currently, a postoperative scoring system to define patients at risk for future weight regain does not exist. Weight loss nomograms to identify patients who fail to lose adequate weight after the initial operation have been described [60]. Evaluating patients with these nomograms can indicate those at risk for suboptimal weight loss during the first year after surgery. Weight loss velocity greater than 2%/week, during the first 14 weeks after surgery, is a good indicator of optimal weight loss at 12-months [60]. Another study by Shantavasinkul et al. identified longer interval and younger age as preoperative predictors for weight regain after RYGB [14], but additional factors are also likely involved in weight regain.
Initial Assessment
Initial evaluation starts begins with obtaining previous bariatric history with particular emphasis on initial weight, the presence of comorbidities, nutritional history, complications from prior operations, and interventions. For RYGB, it is imperative to obtain operative notes of the index operation in order to understand limb lengths, and anatomic relationships, as well technique for pouch formation and G-J anastomosis. In addition, for SG the bougie size, and technique for dissection of the proximal stomach, is important. Any potential intraoperative complications encountered in the initial operation will further help in operative planning. With these details, an organized approach can be followed, to discern if weight gain is related to a complication from the previous operation or an abnormal eating pattern. It is essential to ask if patients feel a sensation of restriction, dumping, or other gastrointestinal symptoms. Most of the time, several factors may play a role in weight regain, and it is difficult to find only one cause. As was stated previously, a multidisciplinary approach is mandatory, and surgeons should be cognizant that weight regain is often not purely a technical issue, which can be resolved by more surgery. Communication with the previous surgeon is encouraged but not always possible. Finally, a complete anatomical study of the digestive tract is needed using an UGI and EGD. It is essential to evaluate the patients for anatomical alterations already described such as dilatation of the gastric pouch, dilatation of the G-J anastomosis, neo-fundus, G-G fistula, etc., by an endoscopist experienced in the evaluating bariatric patients. More complex studies like CT scan or abdominal MRI are obtained, if necessary.
Management
Medications
Several studies have been conducted to study the effect of adding medications to patients with weight regain in order to achieve better outcomes [61–63]. Medication prescription could be an exciting approach for patients who are not candidates for revisional surgery due to their high surgical risk [61]. Different medications have been used as an adjunct, but phentermine and its combinations with topiramate are the most studied [61–63]. Likewise, RYGB patients have shown the best weight loss when a medication is used as an adjunct for inadequate weight loss or weight regain [61, 62]. Although, pharmacotherapy for supplementing weight loss seems is promising, future investigations are needed to clarify which patients are most suited for medication treatment.
Revisional Procedures for RYGB
Gastric Pouch Banding
Adding a gastric band in order to improve restriction might be an alternative to treating weight regain after RYGB. This option can offer additional weight loss and has shown good outcomes [64–66]. In a systematic review made by Vijgen et al., the authors found that adding a salvage band around the failed pouch could provide additional weight loss in cases of weight regain [67]. This approach has become less common as band usage, in general, has fallen out of favor due to concerns of slippage and erosion .
Pouch Reduction
If investigation of the digestive tract shows a dilated pouch, that is, a volume greater than 30–50 cc, and the patient reports a loss of restrictive feeling when eating, some investigators propose pouch reduction. This can be performed laparoscopically and may include narrowing of the stoma. Ianelli et al. reported their experience with this procedure in 20 patients [68]. EWL at 20-month follow-up was 69.1%, although a 30% complication rate was also reported. Conversely, Parikh et al. did not show any benefit to reducing the pouch size with regard to weight loss [69]. Al-Bader et al. showed their experience with laparoscopic pouch resizing [70]. Authors reported %EWL of 29.1%, with a median follow-up of 14.1 ± 6.2 months, and complication rate of 15.6% [70]. Therefore, longer follow-ups are necessary in order to evaluate the real impact of pouch resizing .
Stoma Reduction and Endoscopic Procedures
Trans-oral outlet reduction (TORe), restorative obesity surgery endoscopic (ROSE), endoscopic sclerotherapy, and endoscopic gastric plication (EGP) have been described for the management of stoma and pouch dilatation. TORe consists of placing different suture patterns (i.e., interrupted or purse-string pattern) to surround the dilated stoma and to reduce stoma size. Recently, Jiranpinyo et al. explored the feasibility of this procedure in 252 patients. The authors demonstrated the safety and feasibility of the technique and demonstrated additional weight loss [71]. Schulman et al. compared the two suture patterns. The purse-string technique offered better %EWL at 12 months compared to interrupted suture (19.8 vs. 11.7, p <0.001) [72].
ROSE is also an endoscopic approach used to decrease the size of the gastric pouch and stoma by placement of anchors to create tissue folds at the stoma and around the pouch wall. Horgan et al. published a multicenter experience using this endoscopic technique in 116 patients [73]. The procedures were performed safely, with no significant complications. At 6-month follow-up, patients reported an increase in satiety and mean %EWL of 18% [73]. Ryou et al. described the use of ROSE in five patients with weight regain. The procedure was successfully carried out in all patients, and mean weight loss at 3 months was 7.8 kg [74].
Sclerotherapy also has been demonstrated to reduce the size of the dilated stoma [75]. By injecting the sclerosing agent into the G-J anastomosis, a scar forms that leads to a decrease in the diameter of the stoma. This procedure seeks to increase the feeling of fullness after meals, but it is not widely used.
Endoscopic gastric plication (EGP), using StomaphyX (EndoGastric Solutions, Redwood City, CA), has been developed to create gastric plications or folds that are held together using polypropylene fasteners placed under endoscopic visualization to reduce the size of the pouch and the G-J anastomosis. Ong’uti et al. described a series of 27 patients using this endoscopic procedure, and they found that patients reached weight loss during the first 6 months after EGP, but they regained beyond that [76]. In a randomized study, StomaphyX was not able to show any difference when compared to a sham procedure, and on account of this, the study was stopped [77].
Conversion to Distal RYGB
RYGB revisional surgery may be challenging technically. Lysis of adhesions must be carried out carefully in order to identify the underlying anatomy precisely. Identifying, measuring, and marking the various bowel limbs by running the bowel both antegrade from the gastric pouch and retrograde from the ileocecal are critical. Distal RYGB is a good option for weight loss, but it not offered as a primary procedure due to its risk of protein-calorie malnutrition [78]. In order to convert a RYGB to a distal RYGB, two different operations can be performed. In the first technique, the alimentary limb is divided next to the jejunojejunal anastomosis, and it is moved distally to create a new anastomosis with a longer biliopancreatic limb and a shorter common channel. The new anastomosis can be created according to a surgeon’s preferences [79–82]. In the other technique, the biliopancreatic limb is divided next to the jejunojejunal anastomosis and moved distally to create a new anastomosis 75 cm proximal to the ileocecal valve resulting in a longer Roux limb [83]. In a recent systematic review, both techniques were demonstrated to be safe; however, the first modification (making a longer biliopancreatic limb) showed better results with regard to additional weight loss but also had the highest protein-calorie malnutrition [84]. Ghiassi et al. [85] reported a retrospective review of 96 patients who underwent conversion to distal RYGB during 5 years. In the first 11 patients, the RYGB was modified by dividing the Roux limb at the jejunojejunostomy and transposing it distally to create a shortened total alimentary limb length (TALL) of 250 to 300 cm. Of these, seven patients developed protein calorie malnutrition and diarrhea requiring a second operation to lengthen the common channel by an additional 100 to 150 cm (TALL 400–450 cm), leading to resolution of all symptoms. The subsequent 85 patients were converted to distal RYGB with TALL 400 to 450 in a single-stage operation. The authors reported a mean body mass index and mean excess weight loss at the time of distalization of 40.6 kg/m2 and 33.6%. At 1, 2, and 3 years after distalization, the mean body mass index was reduced to 34.4, 33.1, and 32.2 kg/m2, respectively , and excess weight loss improved to 41.9, 53.7, and 65.7%, respectively. Diabetes resolved in 66.7%, hypertension resolved in 28.6%, hyperlipidemia resolved in 40%, and sleep apnea resolved in 50% at 1 year. The 30-day complication rate and reoperation rates were 6.3 and 5.2%; an additional 7.3% (7/96) required reoperation for limb lengthening. Hypoalbuminemia developed in 21% at 3 years, but no increase in iron deficiency was observed. Calcium metabolism was affected by distalization to a greater degree as 21% of patients demonstrated low corrected calcium levels, 77% were deficient in vitamin D, and parathyroid hormone levels were above normal in 64% at 3 years.
The variations in techniques described to perform revisional distal RYGB makes it challenging to conclude which technique is better in order to obtain additional weight loss. However, a surgeon experienced in revisional surgery with a multidisciplinary team that is attentive to postoperative nutritional management can optimize results and reduce chances of technical and nutritional complications.
RYGB Conversion to Biliopancreatic Diversion/Duodenal Switch
Primary biliopancreatic diversion/duodenal switch (BPD-DS) is a challenging operation, and the revision of RYGB to BPD-DS is even more so. The conversion can be done as a single- or two-staged procedure depending on surgeon expertise or technical issues encountered during surgery (i.e., anesthesia time, cardiovascular events, etc.). Briefly, the gastrojejunostomy is first taken down, and the continuity of the stomach is established. Then, a modified sleeve gastrectomy is performed, which typically comprises of a fundectomy and transecting the duodenum beyond the pylorus and just above the gastroduodenal artery. A duodenoilelal anastomosis is then constructed using a stapler or is hand-sewn. Finally, the ileo-ileostomy is constructed with a 150 cm alimentary limb and 100 cm common channel. Keshishian et al. published their experience with open BPD-DS as a revisional operation in a cohort of patients with previous vertical banded gastroplasty and RYGB [86]. Twenty-six RYGB patients underwent a BPD-DS, 4 (15%) had leaks related to the gastro-gastrostomy anastomosis, and the %EWL was 67% at 30-month follow-up [86]. Parikh et al. performed BDP-DS in 12 patients [87]. They reported no leaks, and %EWL at 11 months was 63%. Both studies described good weight loss outcomes with acceptable morbidity. Nevertheless, given the small number of patients, it is difficult to draw conclusions about the safety, effectiveness, and indications for converting RYGB to BPD-DS.
Revisional Operations for SG
Sleeve gastrectomy patients may develop loss of early satiety sensation after surgery. Likewise, weight regain can be a manifestation of this problem. If a dilated stomach is demonstrated, an additional restrictive procedure could be offered. Many patients will have a normal anatomic study, so these cases may benefit from adding a malabsorptive component, to improve weight loss and resolution of comorbidities.
Re-sleeve Gastrectomy
The first report of this operation was published in 2003. A female patient, who experienced weight regain after a BPD-DS 3 years prior, underwent a re-sleeve procedure with no postoperative complications and significant weight reduction [88]. Baltasar et al. also described the same concept [89]. Iannelli et al. reported a series of 13 patients with poor weight loss or weight regain. Initial mean pre-sleeve BMI was 44.6 kg/m2 with a lowest BMI at 18 months of 31 kg/m2 after SG and subsequently increased to a mean BMI of 34.9 (28–41) at 23-month follow-up. At 12 months follow-up post-revision, %EWL of 71.4 was achieved. No intraoperative or postoperative complications were reported [90]. Nedelcu et al. reported 61 patients with poor weight loss (28 pts.), weight regain (29 pts.), and gastroesophageal reflux (4 pts.). Preoperative workup demonstrated a neo-fundus or gastric dilatation in all cases. The mean BMI before the primary LSG was 43.2 kg/m2 (range 33.8–67.1). The lowest mean BMI recorded after the primary LSG was 34.6 kg/m2 (range 31.9–59.8), representing %EWL of 51.2% (±26.2) at 19.2-month follow-up. The sleeve revision was performed after a mean of 37.4 months with a mean BMI of 38.1 kg/m2 (range 35.2–59.8). After re-sleeve, the mean BMI and %EWL was 29.8 kg/m2 (range 20.2–41) and 62.7% (±29.2), respectively, at a mean follow-up of 19.9 months [91]. Therefore, re-sleeve seems to be safe and reproducible if a dilated stomach can be demonstrated.
SG to RYGB
Conversion from SG to RYGB is often utilized for the management of GERD, and some surgeons have used it for poor weight loss or weight regain. Technically, it is not as complex, but the surgeon must be aware of adhesions, especially to segments 2 and 3 of the liver and the presence of a hiatal hernia. Casillas et al. reported 48 patients who were converted from SG to RYGB, due to GERD, weight recidivism, or both. The mean pre-SG BMI was 45.9 kg/m2 [92]. RYGB conversion for weight loss or weight regain was performed in 27 patients. In this subgroup of patients, the average preoperative BMI was 40.8 kg/m2; and at 36 months of follow-up, mean %EWL was 16.4%, whereas %TWL was 7.5%. The complication rate was as high as 31% in the entire cohort [92]. Quezada et al. reported 50 SG patients who underwent a conversion to a RYGB [93]. In this cohort, 28 out of 50 patients underwent revision due to weight regain. The lowest BMI after SG ranged from 27 to 31 kg/m2, and the median BMI prior to the revision to RYGB was 33.9–37.9 kg/m2. Post-revision, a of BMI of 24–36 kg/m2 was achieved at 3 years [93]. Iannelli et al. studied 40 patients of whom 29 were due to weight loss failure [94]. The pre-SG BMI mean was 47.7 kg/m2, whereas the mean pre-conversion BMI was 39.2 kg/m2. Post-conversion mean BMI of 30.7 kg/m2 was achieved, representing an additional %TWL of 21.8% (calculated from the weight before conversion). A complication rate of 16% was reported in this series [94]. Carmelli et al. [95] and Gautier et al. [96] also showed %EWL of 66% (16-month follow-up) and 59% (15.5-month follow-up) with a low complication rate. However, both studies had few patients and short follow-up, so it is difficult to accurately analyze the long-term impact on weight loss .
Landreneau et al. presented a retrospective review of 89 patients with previous SG who underwent conversion to RYGB . Eleven patients underwent revision of SG to RYGB for either inadequate weight loss or weight regain following SG. The median pre-revision BMI in this cohort was 48.6 kg/m2 with a change in BMI of 2.3 kg/m2 at 30 days and 7.9 kg/m2 at 12 months. Twelve months following revision, this subgroup experienced percent TWL of 16.1% and percent EWL of 32.7%. Interestingly, the cohort of patients that required revision to RYGB due to complications associated with SG had a median pre-revision BMI of 30.4 kg/m2 and had a post-revision change in median BMI of 2.2 kg/m2 at 30 days and 4.5 kg/m2 at 12 months. This corresponded to a 12-month percent TWL of 11.9%. The group concluded conversion of SG to RYGB is safe and feasible to enhance weight loss [97]. Therefore, RYGB can be an alternative for patients who had weight regain after SG, especially when accompanied by GERD. Future studies with more subjects and long-term follow-up are needed to help us better understand outcomes after these conversions .
SG to BPD-DS
BPD-DS has the best long-term results for weight loss and resolution of many comorbid diseases. SG is one of the steps when performing a BPD-DS, so in sleeve-alone patients “completing” the BPD-DS is a valid option. The BPD-DS , compared to RYGB, after SG, has shown better outcomes. Homan et al. [98] compared both BPD-DS and RYGB. BPD-DS was significantly more successful than RYGB (%EWL 59% and 23%, p = 0.0008, respectively) at a median follow-up of 34 months. In addition, BPD-DS exhibited high complication and nutritional deficiencies rates, but these were not significant [98]. These results were consistent with previous data reported by Weiner et al. [99], who showed better weight loss after a BPD-DS compared to RYGB. In the study of Carmelli et al. [95], BPD-DS was also superior to RYGB and did not show significant complications. Therefore, BPD-DS seems to be a reasonable option to treat SG patients with weight regain and maybe more reasonable for those patients with higher starting BMI (i.e., >50 kg/m2) before SG who did not achieve sufficient weight loss after SG alone. Like primary BPD-DS, these revisional patients need close monitoring in order to detect nutritional deficiencies .
SG to Single Anastomoses Procedures
Recently several investigators have proposed single anastomosis procedures as an alternative operation on the theoretical basis of fewer complications including internal hernias from one less anastomosis. Most data pertaining to single anastomosis operations are for primary surgery [100–102], and only a few publications investigate their role as a second stage or revisional surgery. Sanchez-Pernatute et al. showed results of single anastomosis duodenoileal (SADI) bypass as a second step after SG [103]. Sixteen patients underwent a SADI procedure and showed a mean %EWL of 72% at 2 years. They also reported remission of diabetes in the eight patients that had diabetes. No intraoperative , postoperative or nutritional deficiency were reported [103]. These findings are similar to those reported by other authors that have described weight loss after SADI [104, 105]. However, these patients also need close surveillance after surgery due to the risk of malnutrition. To date, only a few publications are available about mini-gastric bypass as a revisional operation [106, 107]; therefore, no conclusions can yet be made about its effectiveness as a revisional operation.
Endoscopic Revision of SG
Endoscopic approach is attractive to address complications because it is less invasive. There are reports about endoscopic management of dilated stomach after SG. Endoscopic suturing or plication can be performed to reduce the sleeve diameter [108]. However, more definitive literature about this topic is needed before it can be recommended as a revision operation after SG.
Conclusions
Weight regain after bariatric surgery is challenging. The key to success is technical expertise and multidisciplinary team management is to identify all the possible variables that play a role in weight failure or regain after a primary operation. Professional societies must arrive at a consensus and define weight regain or failure accurately.
Conflicts of Interest
The authors have no conflicts of interest to declare.
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