Weight Loss Options for Gastric Bypass Weight Re-Gain
This is a relatively comprehensive list of weight loss options for patients who have regained weight after gastric bypass surgery.
- Non Procedural
- Diet and Exercise
- Weight Loss Medications
- Endoscopic Options
- Surgical Options
Surgical Literature
All of these options are covered below. They are broken down into categories: non-procedural weight loss options, endoscopic weight loss options, and surgical weight-loss options.
Non-Procedural Options
These, of course, include diet and exercise as well as weight loss medications. It should be noted that none of the other options discussed today will work without adhering to a proper diet and exercise regimen. We expect that if you’re pursuing an endoscopic or surgical option, you simultaneously work to optimize your weight-loss behaviors fully. If you’ve not worked to optimize weight loss behaviors, we recommend you slow down pursuing other options until this has been accomplished.
Weight Loss Medications
Our body’s weight is tightly controlled by our brain, acting in conjunction with our gastrointestinal tract to set our body’s weight. The complexities of modern processed foods confuse our body’s weight regulation mechanisms leading to abnormal weight gain. Once the weight is elevated, the body fights forever to keep it elevated by altering our body’s process to increase hunger and encourage weight gain. Weight loss medications, like bariatric surgery, disrupt various portions of the pathway that promote weight gain.
Treating the chronic disease of obesity with medications should be thought of similarly to how we treat other chronic diseases like high blood pressure. Medicines for high blood pressure are used for life to control blood pressure. Similarly, obesity medications, when effective without side effects, should be used for life to maintain weight.
Studies show that weight management medications work best with a behavioral lifestyle program. Modern weight loss medications have made great strides in safety profile and weight loss.
Insurance coverage and cost are some of the biggest challenges to patients taking these medications. If interested and no contra-indications, this should be attempted before further surgery.
Endoscopic Options
Endoscopic Pouch/Stoma Reduction (called Transoral Outlet Reduction (TORe)
Endoscopic procedures are attractive because they don’t involve incisions and are lower risk than surgical options. The most commonly performed and effective endoscopic revisional weight loss procedures use devices to suture and reduce the size of the gastric pouch or the opening between the pouch and the small intestine.
Unfortunately, the amount of weight loss achieved doesn’t meet the goals of most patients. The data three years out from these procedures shows about a 20 lbs weight loss. These can be successful for patients just beginning to gain weight to help curb weight regain.
Surgical Literature
Surgical Options
Here are the surgical options to consider. They can be broken down into three categories:
- Procedures which reduce the size of your gastric pouch
- Procedures primarily aimed at hormonal manipulation
- Procedures that decrease absorption of calories
The following few slides will discuss each procedure specifically. Evaluating your current anatomy should significantly guide procedure choice, risk, and the likelihood of helping you reach your goals.
Those procedures that reduce the size of your gastric pouch are most effective in those with enlarged gastric pouches. These will be less effective if the pouch is already average-sized or small.
The procedure aimed solely at hormonal manipulation is more theoretical and should not be considered for most patients.
Procedures that decrease absorption tend to get the most weight off, but the procedures are the most demanding on you as a patient. These procedures require extra vitamins above and beyond what you’re currently taking. They require extremely strict lifelong follow-up, strict adherence to taking the vitamins, and following the prescribed diet plan, or patients can quickly develop severe permanent complications.
Gastric Pouch Reduction
Band over Bypass
Both adjustable bands commercially known as the Lap Band and non-adjustable bands can be placed around the gastric pouch. As an original procedure, the adjustable gastric band was extremely popular for many years but has fallen off dramatically recently due to poor long-term outcomes and late complications. All of the complication profiles associated with adjustable bands placed initially can occur when placed over the gastric bypass pouch.
With band-over bypass, at five years post revision, data shows about twenty-five percent have a band complication, and eight percent have had another operation to remove the band.
Since so few bands are being performed, there is genuine concern the band company will not be around much longer.
Surgical Literature
Sleeve the Bypass
Sleeving the bypass is a play on words highlighting the similarities to the initial non revisional weight loss procedure, the Sleeve Gastrectomy. In the Sleeve Gastrectomy, a single long staple line is created along the stomach, removing about three-fourths of the stomach.
Similarly, when you sleeve the bypass, a single staple line is created across any combination of the roux limb, the connection of the small bowel to the stomach, and the gastric pouch to reduce size.
Sleeving the Bypass comes in a few varieties based on your current anatomy.
- Cut pouch alone
- Cut along the small intestine, the connection of the small bowel to the stomach, and the stomach pouch
- Cut across the extra roux limb called the “candy cane,” the connection of the small bowel to the stomach, and stomach pouch
All serve to make the pouch and connection between the pouch and small intestine smaller to induce weight loss.
Studies have been small, and weight loss and longevity of weight loss isn’t fully understood.
Surgical Literature
Surgical Pouch Revision
Small research studies have demonstrated significant weight loss for patients with a large gastric pouch by surgically redoing the gastric pouch in a manner that creates a small pouch and a small connection between the stomach pouch and the portion of the small intestine known as the roux limb.
Surgical Literature
Hormonal Manipulation
Remnant Gastrectomy
The remnant stomach that is no longer being used make a hormone called ghrelin that makes us feel the sensation of hunger. Some have proposed the removal of this portion of the stomach to reduce the production of this hunger hormone.
Unfortunately, this has not been studied and, as a result, cannot be recommended at this time.
Decreasing Absorption of Food
Distal Bypass
An operation that aims to decrease the absorption of food tends to induce the most weight loss but is by far the most demanding of you as a patient. It requires an extreme willingness to take vitamins, follow the recommended diet plan, and be seen regularly in lifelong follow-up. If you have not been good at doing these things in the past, this is probably not the procedure for you.
Patients will be required to take extra vitamins above and beyond what is already required of gastric bypass patients. Even when the proper steps are followed, some patients’ vitamin levels will be low, requiring even further vitamins that can be costly in the ballpark of 150 dollars per month.
Patients can develop severe permanent complications when the guidelines are not followed, even for just a few months.
To understand the distal gastric bypass, we must do a quick refresher course on your current gastric bypass anatomy. Remember, it makes a Y configuration.
The roux limb or portion of the small intestine that connects to the small stomach pouch makes one arm of the Y
The bowel leading to the old stomach, known as the remnant stomach, is called the bilio-pancreatic limb that makes the other arm of the Y
The base of the why is called the common channel. It is where the food we eat and gastric juices from the old stomach mix allowing for the absorption of nutrients.
In the distal bypass, the why connection is moved to shorten the common channel reducing the length of the bowel where nutrients are absorbed and triggering hormonal signals that affect our body weight.
Historically the distal bypass created a very short common channel length of about 100 cm. This would lead to significant weight loss for most. However, a high rate of severe vitamin deficiencies, diarrhea, and malnutrition, requiring further surgery to lengthen the channel.
Modern studies have helped to tease out the correct amount of bowel to bypass minimizing complications but maximize weight loss. The studies describe the importance of the Total Alimentary Limb Length abbreviated as the TALL length, which is the length of the small intestine where food travels through our GI tract. So the Total Alimentary Limb Length equals the roux limb plus the common channel.
Results have been best when the roux limb is cut just before the why connection, as shown by the dotted red line, and moved further down the common channel.
Studies show creating a Total Alimentary Limb Length of approximately 400 cm provides the best results for most patients.
Here is a comparison of standard gastric bypass on the left and distal bypass on the right, where the blue dotted circle shows the small intestine that is now bypassed. Even with a Total Alimentary Limb Length, some patients will get severe vitamin deficiencies, diarrhea, and malnutrition that could require reversal surgery.
Surgical Literature
Reversal of Gastric Bypass Conversion to Duodenal Switch/SAIDI-S
Reversal of the gastric bypass and conversion to a duodenal switch is an extensive, technically complicated procedure, as shown by the pictured complex steps. It’s the highest risk surgical procedure. It may not be able to be completed in one operation, and it could require stopping after half of the procedure and returning at another operation to complete. This is overly complex and risky for most patients compared to the distal bypass. In certain circumstances, such as patients with a history of marginal ulcers, this might make sense and should be guided by your anatomy and discussion with your surgeon.
A slightly less complicated version of the duodenal switch called the SAIDI-S procedure cuts down on one required small bowel connection.