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Band Over Bypass
Sometimes gastric bypass patients are not able to maintain their weight loss goals. The Roux-en-Y gastric bypass (RNYGB) has been the most commonly performed bariatric procedure in the United States. Unfortunately the long-term failure rate after RYGB is 20 to 35 percent.[1] For the super obese patients (Body Mass Index >49 kg/m2), this failure rate is as high as 40 to 60 percent.[2]
Failure to achieve or maintain significant weight loss frequently leads patients to seek an additional procedure or surgical revision. Interestingly, the most common reason for reoperation after RNYGB is inadequate weight loss.[3] Revisional open bariatric surgery is surgically difficult, is associated with a very high risk for complications, has a high incidence of trauma to the patient, and in many studies has shown to be of questionable benefit.[4] Now, with the advent of laparoscopic surgery, reoperative bariatric surgery has become more popular due to quicker recovery and decreased wound complications compared to traditional open reoperative surgeries.[5]
Obesity is simply a difficult disease to treat. People who do not achieve or maintain their weight loss goal are often considered failures by the medical community, but if someone is truly committed to reaching a healthy weight, we believe they should not feel like they have failed their Gastric Bypass surgery. Though the general public still doesn’t acknowledge it, “Obesity” is a disease. Gastric Bypass (RNYGB) is a surgical treatment for the disease of Obesity. And if it was any other disease, and the patient did not achieve a satisfactory result, that patient would try every treatment option available until the disease was adequately treated. The same should be true for Obesity. The only situation that should be considered failure is that in which an individual gives up on weight loss, stops trying, and fails to pursue further treatment options.
RNYGB patients lose weight very quickly in the first 30-60 days after surgery, and continue with significant weight loss usually for the first 18-24 months. But then the weight loss typically levels off and all too frequently patients begin to gain some of their weight back. Some patients gain 15% back, others may gain it all back.
Fortunately, there are a number of treatment options for patients who have gained their weight back after RNYGB. The first thing we do in our practice is to figure out why a patient has regained their weight. Is it because they are eating the wrong foods, or is it because they have developed poor eating behavior (eating at odd hours of the day, stress eating, eating out of anxiety or depression, and the like), or because they aren’t exercising? Or is it actually because they have lost their feeling of fullness or satiety after eating only a small meal and are now eating much more than they did right after surgery? In addition, is it because they now get hungry between meals and find themselves eating more often and more volume to compensate? Sometimes it’s simply a combination of poor eating behavior, a loss of satiety, and the return of hunger. This is why it is so absolutely critical to seek help from a “Comprehensive Multidisciplanary Obesity Care Center.” A patient must be able to get help for all of the problems that they are facing, because attempting to treat one without treating the others is just another recipe for failure.
For now, we will focus on treatment for patients who have no other issues and merely have regained their hunger and have lost their sense of fullness. Most likely they are suffering from a dilated pouch and/or a dilated stoma (connection from the surgically created stomach pouch to the small intestine). Less commonly, these symptoms can be caused by a gastro-gastric fistula (an abnormally present connection from the surgically created stomach pouch to the larger bypassed stomach pouch).
There are several surgical options for dealing with a dilated pouch and/or dilated stoma:
1. Reversal of the RNYGB and Conversion to a Duodenal Switch is the most drastic, most complex, and most dangerous option and has a significantly higher complication rate[13].
2. Conversion to a “distal gastric bypass” where the small intestine is disconeected from it’s surgical connection and re-connected to a point much further downstream (close to the colon). Studies have shown that a large number of patients develop severe protein malnutrition (and many require repeat surgery for this).[9] A recent study found no significant differenece in weight loss or reduction in comorbid illness at 4 years. [11]
3. Surgical Revision with reduction of the pouch size and revision of the stoma by taking apart the connection of the stomach to the intestine (anastamosis) and revising it by making a new anastamosis. A significant number of these patients require an additional revision procedure later. This procedure has been shown to be of questionable benefit and has a significantly increased risk. The risk of leak alone is 4X that of the original operation. One large study in the US reported a 50% complication rate and negligible weight loss.[4]
4. Gastric Banding. Placement of a gastric band (Lap-Band® or Realize™ band) around the upper stomach pouch has been evaluated in several studies (including several in the United States) and has been shown to be very safe and effective as a revisional procedure. The gastric band helps patients to feel full sooner with only a small portion of food, and stay full longer. Therefore a patient will no longer be hungry and will not be constantly looking for food.
5. Endoscopic/Endolumenal Procedures. Incisionless procedures done through the mouth, using new state of the art technology to reduce the size of the dilated pouch and/or the dilated stoma. ROSE, StomaphyX, and EndoCinch are three such device technologies. With these devices, a surgeon can place special sutures or fasteners through the stomach tissue at the stoma and in the pouch which can reduce the size of an enlarged pouch and a dilated stoma. By making the stoma and/or pouch smaller again, we can restore the sense of fullness (early satiety), and reduce a patient’s hunger to where they were successfully losing weight. Though these systems are somewhat similar, we have chosen the ROSE procedure (Restorative Obesity Surgery Endolumenal) as we believe the technology to be superior to the others. Experience with this technology and this procedure has shown promising results.
Gastric Band over Gastric Bypass (BOB):
The Lap-Band® or Realize™ band can give new hope to those who have regained weight after gastric bypass surgery (RNYGB).
We can place a gastric band around the previously surgically created gastric pouch to restore early and prolonged satiety (sense of fullness) and diminish hunger with very good results. With restoration of fullness and loss hunger, comes restored success.
You may be a candidate if you have had a gastric bypass with:
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Loss of early satiety, prolonged satiety, or restriction and therefore have the ability to eat more.
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Significant weight regain after significant initial weight loss.
1. Christou N, Look D, MacLean L. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years. Ann Surg 2006;244:734–40.
2. Prachand V, DaVee R, Alverdy J. Duodenal switch provides superior weight loss in the super-obese (BMI>50Kg/m2) compared with gastric bypass. Ann Surg 2006;244:611–9.
3. Behrns K, Smith C, Kelly K, Sarr M. Reoperative bariatric surgery—Lessons learned to improve patient selection and results. Ann Surg 1993;218:646–53.
4. Schwartz R, Strodel W, Simpson W, Griffen W. Gastric bypass revision: lessons learned from 920 cases. Surgery 1988;104:806–12.
5. Gagner M, Gentileschi P, De Csepel J, et al. Laparoscopic reoperative bariatric surgery: Experience from 27 consecutive patients. Obes Surg 2002;12:254–60.
6. Muller M, Rader S, Wildi S, et al. Matched pair analysis of proximal vs. distal laparoscopic gastric bypass with 4 years follow-up. Surg Endosc 2007;21:S369.
7. Keshishian A, Zahriya K, Hartoonian T, Ayagian C. Duodenal switch is a safe operation for patients who have failed other bariatric operations. Obes Surg 2004;14:1187–92.
8. Parikh M, Bessler M. Revision Procedures for Failed Gastric Bypass. Bariatric Times Surgical Prospective 2007
