Management of Weight Regain
Clinical Case Post Bariatric Surgery
Case Study Teaching Workshop
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MOURNING
Age: 56 yearsBMI: 37,3 kg/m2
T2DM in metforminMild depression in the past
Long-standing obesityRegular eating at mealsSometimes snacking at home
The case of Rosella
Bariatric Surgery: Weight regain
Schauer PA. NEJM 2017;376:641
Peterli R. JAMA 2018;319:255
Bariatric Surgery: Weight Regain
Adams T et al. NEJM 2017;377:1143
Bariatric Surgery: Weight regain
Kofman MD et al. Obesity 2010;18:1938
497 RYGB patients: 81% MAX EWL → 70% EWL 3-10 yrs after surgery (mean 4.2 yrs)
Bariatric Surgery: Weight regain
Question 1. What you should perform FIRST for Rosella?
• Revisional Surgery
• Reinforcement of the lifestyle modifications programme
• Prescription of a weight-loss drug
• Evaluation of the functionality/anatomy of the first procedure
Bariatric Surgery: Weight regain
Question 1. What you should perform FIRST for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
• Revisional Surgery
• Reinforcement of the lifestyle modifications programme
• Prescription of a weight-loss drug
Bariatric Surgery: Weight regain
II) Surgery-related: - Adjustable gastic banding: Pouch distensionBand removal
- Roux-en-Y bypass: Stoma dilatationPouch dilatationGastro-gastric fistulae
- Sleeve Gastrectomy: Sleeve dilatation
I) Patient-related: - Dietary non-compliance: Poor diet qualityInappropriate food choicesLack of nutritional counseling
- Mental health disorders: Binge eatingGrazing behaviours
- Physical inactivity
- Hormonal/metabolic: GhrelinGlucose homeostasis
Karmali et al. Obes Surg 2013;23:1922-33
Bariatric Surgery: Weight regain
EGDS: Normal for LSGRx Upper digestive tract: Normal for LSG
LABS data:
- Normal HbA1c- No micronutrients deficits
The case of Rosella
Question 2. What you should perform SECOND for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
• Revisional Surgery
• Reinforcement of the lifestyle modifications programme
• Prescription of a weight-loss drug
Bariatric Surgery: Weight regain
Question 2. What you should perform SECOND for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
B. Reinforcement of the lifestyle modifications programme
• Revisional Surgery
• Prescription of a weight-loss drug
Bariatric Surgery: Weight regain
Mitchell JE et al. JAMA Surg 2016;151:752
Bariatric Surgery: Weight regain
Rudolph A & Hilbert A. Obes Rev 2013;14:292
Bariatric Surgery: Weight regain
Rudolph A & Hilbert A. Obes Rev 2013;14:292
Bariatric Surgery: Weight regain
There was a positiverelationship between
increased exerciseand weight loss aftersurgery in 15 studies
Bariatric Surgery: Weight regain
Bariatric Surgery: Weight regain
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LIFESTYLE REINFORCEMENT
The case of Rosella
Question 3. What you should perform THIRD for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
B. Reinforcement of the lifestyle modifications programme
• Revisional Surgery
• Prescription of a weight-loss drug
Bariatric Surgery: Weight regain
Question 3. What you should perform THIRD for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
B. Reinforcement of the lifestyle modifications programme
C. Prescription of a weight-loss drug
• Revisional Surgery
Bariatric Surgery: Weight regain
Question 3bis. Which drugs do you suggest for Rosella?
o Xenical
o Liraglutide 3.0 mg
o Fixed combination Naltrexone / Bupropion
Bariatric Surgery: Weight regain
Schwartz J et al. Obes Surg 2016;26:452
Bariatric Surgery: Weight regain
Stanford FM et al. SOARD 2017;13:491
The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study
MethodsWe completed a restrospective study to identify patients who had undergone bariatric surgery in the form of a Roux-en-Y gastric bypass (RYGB) or a sleeve gastrectomy from 2000–2014. From this cohort, we identified patients who were placed on weight loss pharmacotherapy postoperatively for inadequate weight loss or weight regain. We extracted key demographic data, medical history, and examined weight loss in response to surgery and after the initiation of weight loss pharmacotherapy.
ResultsA total of 319 patients (RYGB = 258; sleeve gastrectomy = 61) met inclusion criteria for analysis. More than half (54%; n = 172) of all study patients lost≥5% (7.2 to 195.2 lbs) of their total weight with medications after surgery. There were several high responders with 30.3% of patients (n = 96) and 15% (n = 49) losing≥10% (16.7 to 195.2 lbs) and≥15% (25 to 195.2 lbs) of their total weight, respectively.
Bariatric Surgery: Weight regain
Toth AT et al. Children 2018;5(9)
Bariatric Surgery: Weight regain
Rye P et al. Obes Surg 2018;28:3553
Bariatric Surgery: Weight regain
Hanipah ZN et al. SOARD 2018;14:93-98
209 pts
156 pts (74.6%)
25 pts (12.0%)
18 pts (8.6%)
10 pts (4.8%)
Bariatric Surgery: Weight regain
Hanipah ZN et al. SOARD 2018;14:93-98
Bariatric Surgery: Weight regain
60
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100
0 1 2 3 4 5 6 7
Kg
Anni
LSG
MOURNING
LIFESTYLE REINFORCEMEN
NALTREXONE/BUPROPIONE
The case of Rosella
Question 3. What you should perform FORTH for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
B. Reinforcement of the lifestyle modifications programme
C. Prescription of a weight-loss drug
• Revisional Surgery
Bariatric Surgery: Weight regain
Question 3. What you should perform FORTH for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
B. Reinforcement of the lifestyle modifications programme
C. Prescription of a weight-loss drug
D. Revisional Surgery
Bariatric Surgery: Weight regain
Bariatric Surghery: Weight regain
Angrisani L et al. Obes Surg 2018
WEIGHT REGAINPOST BS
RE-DO SURGERY
Bariatric Surgery: Weight regain
WEIGHT REGAINPOST BS
RE-DO SURGERY
- The risk of surgical complications is higherthan in primary procedures.
- We have no good quality data on weightloss in the long-term.
- Tendency to shift toward malabsorptiveprocedures with a higher risk of long-termnutritional complications.
Bariatric Surgery: Weight regain
Bariatric Surgery: Weight regain
The first consensus statement on revisional bariatric surgery using a modified Delphi approach.
BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS.METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus.RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%).CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.
Surg Endosc 2019 Jun 19. doi: 10.1007/s00464-019-06937-1. [Epub ahead of print]
What you should perform for Rosella?
A. Evaluation of the functionality/anatomy of the first procedure
B. Reinforcement of the lifestyle modifications programme
C. Prescription of a weight-loss drug
D. Revisional Surgery
Bariatric Surgery: Weight regain
Bariatric Surgery: Weight regain