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Put simply, the “perfect” weight loss operation does not exist nor has it ever. All weight loss operations have limitations and weight regain can occur for a variety of reasons. If this has happened in your life we want you to realize that you are not alone, you haven’t “failed” and help is available. In addition, much has been learned about weight regain over the past few years and effective treatment options are now available.
To begin, we routinely perform a comprehensive medical evaluation and occasionally find patients with treatable medical conditions as the cause. In the absence of a non-surgical cause we turn our attention to the previous operation, study the current anatomy and explore common reasons for inadequate weight loss or weight regain.
For those who have experienced complications with a specific operation we offer the depth and breadth of surgical experience to help solve the problem. Because this represents a diverse set of issues there is no overall consensus on what constitutes the “best” treatment in this area of bariatric surgery. However, below are listed some of the more common problems that Dr. McCarty has successfully treated along with select brief descriptions and has over 20 years of revision experience.
LAGB gained popularity because of its relative ease to place, low operative risk and because it was considered “reversible”. While some patients have success with this procedure, many encounter problems over the ensuing years. Expected weight loss is often less than desired and multiple “adjustments” are often required. Naturally this can be inconvenient, painful, frustrating and expensive. More concerning however, is the unique ability of the band to cause scar tissue around the stomach, leaking of the band or port itself, slippage of the stomach through the band, erosion of the band through the stomach, infections associated with the port, significant esophageal reflux with dilation of the esophagus, among others. Band removal rates of 50% or more within 10 years have been reported.
The truth is, LAGB was marketed as an easy, safe and reversible operation that resulted in high revenues for the companies who produced them, surgeons who placed them and hospitals/surgery centers in which they were placed. This is not to say that they are not effective for some, but many patients have problems after having made a significant financial investment to fight obesity. All too often they are left disappointed, frustrated and financially drained.
For these and other reasons many patients with problems have the band removed or converted to another weight loss procedure. Most commonly, the band is removed (along with the port) and converted to a gastric bypass or gastric sleeve. These options still serve as effective procedures following the removal of the band. We most commonly revised the LAGB to a gastric sleeve and have seen excellent results. We often perform this using an endoscopic approach that usually requires a one night hospital stay. Recovery time is shorter compared to conventional laparoscopy.
It is not uncommon to regain ~10% of total weight lost 5-10 years following a gastric bypass. If weight gain continues it frequently causes great concern and anxiety. The most common reason for continued weight gain is a dilated gastric pouch and/or anastomosis of the pouch and small intestine. This is often the result of increased hunger over the years with stretching of the pouch and pouch outlet. This is one of the most common problems we treat and our goal is losing ALL of the regained weight. This is can be performed with a NOTES approach with an average hospital stay of 1 day.
Of note are some other interventions that have proved disappointing and/or problematic. First, an LAGB can be placed around the pouch to restrict food intake. This is relatively easy but has not been effective in our experience. Second, recent studies have demonstrated a very modest improvement (5-10 lbs weight loss at 6 months) by injecting the anastomosis with a toxic chemical to induce scarring and a subsequent reduction in the size of the anastomosis. The technique is termed “sclerotherapy”. The results have been modest with success touted as “weight stabilization” or a loss of ~10 lbs. Most patients who have regained a substantial amount of weight following a gastric bypass will be disappointed with these results. While simple to perform, we have seen several patients with complications, including severe gastro esophageal reflux disease with resultant asthma, aspiration pneumonitis and even aspiration pneumonia. In the group of sclerotherapy patients that have visited our clinic, none had lost weight and most had the procedure performed multiple times.
This operation was very popular in the 1980s and creates a small stomach pouch that limits food intake. While effective for weight loss, many patients have trouble tolerating substantial solid food because the silastic band causes scar tissue formation. Healthy foods like meat and vegetables often result in vomiting so a natural progression to tolerable foods ensues. This is most commonly creamy soup, chips and candy, and dramatically limits weight loss. In addition, the pouch can open (staple line disruption) and results in a lack of restriction of food. While these operations were performed through an open incision we can correct these problems by laparoscopic and/or endoscopic techniques. This can be converted to a more effective result by revising the VBG to a gastric sleeve, gastric bypass or duodenal switch. Long-term results are similar to a primary procedure.
When adequate weight loss is not achieved following a sleeve gastrectomy it is most likely because the expected weight loss following surgery is not satisfying to the individual patient. We recommend converting the sleeve to a gastric bypass or duodenal switch, which is relatively easy and effective.
