Gained Weight After Gastric Bypass?
Obesity is an epidemic in the US, affecting 40 percent of adults in 2016. As obesity numbers rise, bariatric surgery remains the top choice for treatment. Studies show that over 90 percent of bariatric patients lose more than half of their excessive body weight after surgery.
Among bariatric surgeries, the Roux-en-Y gastric bypass (RYGB) procedure has been the gold standard until it recently lost its top spot to a newer, less invasive procedure known as sleeve gastrectomy. But even as RYGB procedures become less common, there are many post-RYGB patients who, despite having lost weight in the first few years following surgery, are seeing significant weight regain eight-to-ten years later.
“The average person who undergoes gastric bypass will eventually regain 20 to 30 percent of the weight they initially lost. About a third of patients will gain back nearly all of their lost weight,” says Pichamol Jirapinyo, MD, MPH, an advanced endoscopy fellow in the Division of Gastroenterology, Hepatology and Endoscopy of the Department of Medicine at Brigham and Women’s Hospital (BWH).
It’s common to gain weight back after gastric bypass surgery
People who regain weight after bariatric surgery often experience a range of negative emotions, such as disappointment, shame, or frustration. Yet since studies show that it’s common to regain weight, this should be viewed not as a personal failure, but rather a medical reality.
“This problem is quite common after gastric bypass, so you’re not alone. We know that bariatric patients will gain some of the weight back long-term, and we can work together to help you lose the weight again,” says Dr. Jirapinyo.
Weight regain is often related to the anatomy of a post-RYGB patient
Gastric bypass surgery changes the anatomy of the stomach and small intestine. During surgery, the stomach is connected to the second part of the small intestine. This new connection is called a ‘gastrojejunal anastomosis,’ or an ‘outlet.’
Over time, the outlet dilates (stretches open), and this widening can cause weight gain. Because it’s common for the outlet to widen, people frequently face weight regain years after gastric bypass.
The anatomy of the stomach before and after Roux-en-Y gastric bypass. The outlet occurs at the bottom of the new stomach pouch (green).
Minimally invasive options for post-RYGB patients experiencing weight gain
Bariatric surgeons rarely recommend a second surgery after RYGB, as repeat procedures may carry risks. Fortunately, it’s not necessary to have another surgery to treat weight regain because there are many options available to post-RYGB patients who are struggling with their weight, including endoscopic procedures, medication and lifestyle adherence.
The goal of endoscopic procedures is to shrink the size of the outlet. Shrinking the outlet induces weight loss and may also affect hormone levels in a way that reduces hunger. Post-RYGB patients can have outlets that range from 20 to 40 millimeters; the target size for the outlet is eight-to-ten millimeters.
“An endoscopic procedure is a great option for people who don’t want to undergo another weight-loss surgery,” says Dr. Jirapinyo. “These procedures are quick and minimally invasive, performed through one’s mouth. They are also reproducible, so if you start gaining again, you can return for a follow-up procedure.”
Complications are few and rare. They may include bleeding, which can be countered with anti-acid medications. The outlet may become too small, but that can also be reversed.
Brigham and Women’s Hospital regularly performs three endoscopic procedures to treat weight regain. The choice of procedure is a combination of patient preference and physician recommendation, and your doctor will work with you to find the most appropriate procedure.
1. Argon Plasma Coagulation (APC)
During an APC procedure, a laser is applied to the outlet, causing it to shrink and become firmer. The procedure takes about 10 minutes and the patient returns home the same day. A few visits are usually necessary: The procedure is repeated every three months until the outlet size is reduced to eight-to-ten millimeters.
Early data shows that patients who undergo APC lose approximately five-to-eight percent of their initial weight after one year.
2. Transoral Outlet Reduction (TORe)
A TORe procedure involves placing stitches around the outlet to reduce its size. The procedure takes about an hour. TORe helps not only with weight loss, but also with issues that frequently accompany obesity, including hypertension, diabetes and high cholesterol.
Data shows that after a year, patients lost 8.4 percent of their initial weight with its efficacy lasting up to at least 5 years.
Plication involves folding the tissues around the outlet inward to reduce its size. The concept of plication is similar to suturing, but the devices differ. BWH’s Endoscopy Center is the only location in the US where endoscopic gastric plication is currently performed for weight regain after RYGB.
Ongoing studies show that in 6 months patients lost on average 10.7 percent of their initial weight.
There are five FDA-approved prescription medications for weight loss. These medications function in different ways. Some help you feel less hungry, while others make it more difficult for your body to absorb fat from food. Weight-loss medications work best when combined with lifestyle changes, such as regular exercise and a healthy diet.
It’s always recommended to reflect on one’s lifestyle, specifically eating well and staying active. Diet and physical exercise contribute to weight fluctuations even if they are not the sole cause of weight regain.
Before an endoscopic procedure at BWH can be considered, patients are evaluated for adherence to lifestyle changes. “We only want to put patients through a bariatric procedure if they are committed to maintaining a healthy lifestyle afterwards,” says Dr. Jirapinyo. “An endoscopic procedure must be performed alongside a commitment to eating well and exercising.”
The multidisciplinary approach at BWH
Brigham and Women’s Hospital takes a multidisciplinary approach to bariatric surgery and endoscopic treatments at our Endoscopy Center.
“We all work together as a team,” says Dr. Jirapinyo. “We evaluate our patients before and after the procedures in the bariatric endoscopy clinic, led by Christopher Thompson, MD, MHES. Additionally, we work closely with our bariatric surgeons, nutritionists, psychologists and medical bariatrician colleagues.”
Weight regain after RYGB is common and many studies are starting to reveal why. Dr. Jirapinyo emphasizes that people should be aware of the resources available to them.
“If you suffer from weight regain, please seek advice,” she says. “Don’t suffer through it alone. A lot of people have this problem and we have effective and minimally-invasive solutions to treat it.”
- Anna G.