Some Reflections On Weight Regain After Bariatric Surgery
The Mercy Bariatrics approach in Perth, WA
Dr Leon Cohen Updated Sept 2020
After over 15 years in Bariatric surgery I have learnt one fundamental truth: Morbid obesity is a lifelong and resilient disorder. The body is always trying to get back to its peak weight and brings into play multiple powerful mechanisms to do this.
All of this is under the control of the deepest most primitive part of our brain… the hypothalamus. This controls our breathing, our heart rate our temperature our sleep patterns. It senses our peak fat mass by a chemical called leptin and always tries to restore back to that level. If you think you can win an argument with your hypothalamus try holding your breath for three minutes and see who wins on that one!
The Same Pattern
As powerful as bariatric surgery can be, long term observation of all the current bariatric operations all show the same pattern: people reach a peak weight loss around 2 years, are stable for a few years then slowly start to regain a small amount of weight.
This is why I start off with all my patients telling them “All bariatric operations are going to fail to some extent over time”.
As depressing as this may sound once you accept this truth it is actually quite a powerful incentive to maximise the initial weight loss, reign in bad habits and also reinforce the need for regular followup.
It also helps to diffuse the guilt which a lot of patients have over their regain…. that it is all their fault!
I never blame a patient for their weight regain. My only frustration is that they don’t return sooner before we have such a long way to catch up!
Actually the responsibility for weight regain needs to be spread around:
- The physiology of your gut, metabolism and hypothalamus… outside your control.
- Your habits of eating and excercise… within your control.
- Returning for followup ….. Shared responsibility.
- The construction / design of your surgery… under your surgeons control.
Weight regain is a complex interplay between these factors and the impact of each has to be considered and addressed.
Considering Sleeve Gastrectomy
I have been performing Sleeve Gastrectomy now since 2004 and after over 1400 sleeves there is nothing I have seen that hasn’t firmed up my view that it is a fantastic and very durable operation and my first choice for the majority of patients.
As our program has evolved we have moved to smaller and smaller bougie sizes( The rubber rod used to calibrate the width and volume of your sleeve) to give the smallest possible stomach size commensurate with a good quality intake postoperatively:
2004-2006: 50 Fr – 100 cases
2006-2010: 40 Fr – 760 cases
2010-2016: 36 Fr – 560+ cases.
The small 36 fr bougie is our “go to size” for most cases , except if BMI < 35 or the client needs better drinking capacity because they work in the heat. With each downward reduction in bougie size we have seen an approx 10% better excess weight loss.
We also see a lower re-operation rate. So in our three series I have had to revise of my patients 24/100 50Fr, 8/760 40Fr and so far no 36Fr. I have also revised another 36 patients from other units in whom the bougie size was not known.
This Has Led Me To Believe That Size Does Matter!
The smaller the initial size of the stomach tube the better the weight loss and the less the regain of weight.
Another technical issue is that some surgeons felt the need to leave more of the antrum (lower part of stomach) and this may also have stretched up over time.
Finally patients who previously had an adjustable gastric band which was on too tight for too long may have stretched up their oesophagus above the band which after sleeving may act as a reservoir to food.
Inevitably however the gastric tube will stretch a little over time and eating capacity will increase.
The Rice Cream Test
We have been interested in this from the beginning and devised a functional assessment of gastric capacity… the rice cream test. In this test we asked patients to eat as much of a can of rice pudding at a consistent pace until they recognise:
- The point at which they are feeling satisfied (Satiety volume)
- The point at which they can eat no more (Maximum tolerated volume)
In the majority of patients whose capacity approaches a whole can of rice cream weight regain is common, I would say almost inevitable.
Not Just About Capacity
However it’s not just about capacity. It’s also about frequency of eating and making the wrong choices of food. Reluctance to exercise will compound the problem.
So some patients who have a measured small volume stomach will have sabotaged themselves by:
- Drinking excessive alcohol each day (one bottle of white wine adds 650 Kcal to your daily caloric intake and can easily push you over the threshold of weight regain)
- Snacking and grazing on high calorie carbohydrates.
- Drinking a lot of sugary drinks and milky coffee ( each flat white is 150 Cal)
Other Important Factors:
- Falling pregnant
- Being on some antidepressants
So How Do We Assess And Address Weight Regain?
- Assess which factors are exerting their influence on the patient by a detailed diet history, weight loss history and activity history.
- Assessment of the gastric capacity . This may involve Radiological tests such as a barium meal or Fizz CT as well as the Ricecream test.
- Evaluate the sleeve by endoscopy looking for hiatus hernia and reflux.
Outcomes Of Re-sleeve Gastrectomy Personal Series 31 Case:
What Other Options?
If patients have a relatively small volume sleeve and their weight gain is due to snacking and carbohydrate intake they may do better with a Bypass operation such as as SASI-S bypass which brings into play a more powerful hormonal effect of satiety hormones / Gut Incretens whilst preserving optimal Micronutrient absorbtion. ( See SASI-S Bypass )
In all cases of weight regain participation in the Back on Track program is an integral part of re-establishing correct weight loss behaviour.
Mercy Bariatrics Perth
If you are experiencing weight regain after bariatric surgery, please do not hesitate to contact Mercy Bariatrics. We are here to help you.