This is a relatively comprehensive list of weight loss options for patients who have regained weight after sleeve gastrectomy surgery.
- Non Procedural Options
- Diet and Exercise
- Weight Loss Medications
- Endoscopic Options
- Surgical Options
- Anti-Reflux Options – Coming Soon
Non-Procedural Options
Let’s begin talking about the 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 maximize 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 our weight is elevated, the body fights forever to keep it elevated by altering our body’s processes 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 Sleeve Reduction
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 sleeve.
Unfortunately, the amount of weight loss achieved doesn’t meet the goals of most patients. Studies showed an average of about 27 lbs lost at one-year post procedures and very little data on durability beyond this time.
Surgical Literature
Surgical Options
Here are the surgical options to consider. They can be broken down into two categories those which reduce the size of your sleeved stomach and those which decrease absorption. The following few slides will discuss each procedure specifically. Evaluating your current anatomy with endoscopy or upper gastro-intestinal x-ray series should significantly guide procedure choice, risk, and the likelihood of helping you reach your goals.
Those procedures which reduce the size of your gastric sleeve are most effective in those with dilated or inadequately sleeved stomachs. These will be less effective if the sleeve is already average-sized or small.
Procedures that decrease absorption tend to get the most weight off, but these procedures are the most demanding on you as a patient. Some of these procedures require extra vitamins above and beyond what you currently take. They need rigorous lifelong follow-up, strict adherence to taking the vitamins, and following the prescribed diet plan, or patients can quickly develop severe permanent complications.
Surgically Reduce Stomach Size
Band Over Sleeve
Both adjustable bands (i.e., the Lap Band) and non-adjustable bands can be placed around the gastric sleeve. As an original procedure, the adjustable gastric band has been a popular procedure for many years, but it has fallen dramatically in recent years 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 sleeve.
With band over sleeve, there is very little available research data, but one small study suggested about 30 lbs weight loss on average.
Since so few bands are being performed, there is genuine concern the band company will not be around much longer.
Surgical Literature
Re-Sleeve
Re-sleeve maintains the original configuration of the sleeve gastrectomy. Since the original sleeve should have removed approximately 80% of the stomach, it can only be performed when the original sleeve was left abnormally large or is currently significantly dilated.
Surgical Literature
Decrease Absorption
Unlike the original sleeve gastrectomy and the previously discussed revisional options, the following options all involve altering the small bowel anatomy in a way that bypasses portions of the small intestine where the majority of nutrients from food are absorbed. In the modern era, our understanding of how this works is less about decreasing food absorption and more about amplifying hormones that help our brain set our body’s weight. The greater the hormonal manipulation, the more weight loss and resolution of obesity-related co-morbidities. In our list working downward from conversion to roux-en-y gastric bypass toward conversion to duodenal switch, each step represents more small intestine being bypassed, translating to more significant hormonal manipulation and thus more weight loss. However, the downside of more intestines being bypassed is higher chances of vitamin deficiencies and malnutrition.
Conversion to Roux-En-Y Gastric Bypass (RYGB)
Roux-en-y Gastric bypass is one of our primary bariatric procedures. To convert a sleeve to a gastric bypass, the sleeve is divided. To create a small gastric pouch. The bowel is reconfigured, as shown in this traditional gastric bypass animation.
As initial bariatric procedures, sleeve and gastric bypass lose similar amounts of weight initially. Over time gastric bypass tends to be more durable in weight loss. The additional weight loss results have been mixed when used as a revision from sleeve to gastric bypass.
For sleeve patients suffering from acid reflux or those who have developed Barrett’s esophagus, gastric bypass is typically considered the best anti-reflux operation.
Patients with gastric bypass are at risk of marginal ulcers. A marginal ulcer is a small ulcer just past the gastric pouch on the small intestine. They occur about 4% of the time but are at increased risk in patients who smoke, take NSAID medications, or oral steroid medications. If you are at increased risk for marginal ulcers, you probably should consider other options.
Internal hernia are spaces in the abdomen where the bowel can be trapped and, in worst-case scenarios, can cut off blood supply to the trapped bowel requiring emergent surgery. Any operation can form scar tissue that can create a space for internal hernias to develop. Any operation where a bowel connection is formed creates spaces where you can form internal hernias.
These spaces are closed at the time of surgery but in bariatric surgery, what is shut are layers of fat that can melt away with weight loss and open up at a higher rate than after non-weight loss operations that involve a bowel connection. Gastric bypass has two locations where internal hernias can form, which could require further surgery down the line.
Surgical Literature
Conversion to One Anastomosis Gastric Bypass (OAGB)
One anastomosis gastric bypass known as OAGB is a standard procedure outside of the United States but is very new in the United States and still has minimal insurance coverage. On average, it bypass’s more intestines than roux en y gastric bypass or RYGB, resulting in more weight loss but more significant vitamin deficiencies and malnutrition. It’s a slightly more straightforward operation with one less connection. However, by not making this connection, patients are at increased risk for bile reflux. Long-term Bile reflux has a theoretical concern of increasing esophageal cancer risk.
Overall, OAGB patients are at lower risk for marginal ulcers than RYGB but should still avoid marginal ulcer risk factors like smoking, non-steroidal anti-inflammatory drugs use, and oral steroid use.
Regarding internal hernias, OAGB has only one potential internal hernia space compared to RYGB, which has two potential internal hernia spaces.
Surgical Literature
Conversion to Single Anastomosis Duodenal Ileal Bypass With Sleeve (SAIDI-S)
The SAIDI-S is a somewhat new variant of the duodenal switch. It involves one less bowel connection than the duodenal switch leading to less operative time and surgical risk. However, while low overall risk, both procedures involve dissection around a surgically complicated portion of the anatomy, the first portion of the intestine known as the duodenum, and are at higher surgical risk than the other procedures.
If you compare the OAGB and SAIDI-S, the bowel connection is made at different locations relative to the stomach. In the SAIDI-S, the connection is made just past the stomach on the first portion of the intestine.
A muscle at the end of the stomach known as the pylorus helps lessen the potential for bile reflux which is of concern with the OAGB. The intact pylorus also reduces the likelihood of dumping syndrome and reactive hypoglycemia, which can be a concern with the RYGB and OAGB.
Making a connection between the duodenum and small intestine as is done in the SAIDI-S and duodenal switch is at much less risk of marginal ulcers than connections to the stomach as done with the roux-en-y gastric bypass and OAGB. As a result, with the SAIDI-S, patients can better tolerate NSAID medications and oral steroids if required.
Another difference between the SAIDI-S and the OAGB is the amount of small intestine bypassed. With the SAIDI-S, more intestine is bypassed, resulting in more significant weight loss but higher rates of vitamin deficiencies. As a result, patients must take more vitamins above and beyond what you currently take. If vitamins are missed even for relatively short periods, vitamin deficiencies can lead to severe permanent complications.
Surgical Literature
Conversion to Duodenal Switch (DS)
The sleeve gastrectomy originated from surgeons performing the duodenal switch operation as a two-staged procedure for high-risk patients. The sleeve portion would be completed in one operation. Passage of time allowed for weight loss and improvement of obesity-related medical conditions. This would risk reducing the potential complication profile for a planned return to complete the small intestine portion of the duodenal switch.
Many patients were satisfied with weight loss after the sleeve portion and didn’t return for the second portion, which eventually became a stand-alone primary procedure. Converting to a duodenal switch leaves the existing sleeve in place and completes the small bowel bypass portion of the procedure. If significant weight has been re-gained or new co-morbidities have developed, the risk reduction benefits of the sleeve may have been lost. Surgical complications of all of our bariatric surgeries are low, but the duodenal switch is our most technically demanding procedure and, thus, the highest risk.
The duodenal switch was performed as early as the 1970s, so we have long-term research studies on its results. It bypasses more small intestines than any of the other bariatric procedures producing the most significant hormonal effects and resulting in the most weight loss and most durable weight loss. It also results in the greatest resolution of obesity-related medical conditions.
However, it is by far the most demanding on you as a patient. It requires you to take extra fat-soluble vitamins in addition to those you’re currently expected to be taking. The vitamins can be quite costly, and you need to consider the stability of your finances because missing the vitamins, even for short periods, can result in severe permanent complications. In general, patients who do best with duodenal switch are those personality types who diligently follow the rules in life. If following the rules is not your strength, you should not consider the duodenal switch. Those who get this wrong and select this procedure due to the allure of more significant weight loss but don’t follow the rules end up with new problems that are often worse than any current conditions.