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There are many strategies for nonsurgical weight reduction (e.g. pharmacotherapy, dieting, physical exercises, behavioral modification, and psychotherapy), but either individually or in combination they usually result in a high weight recidivism rate. In contrast, bariatric surgery has been shown to provide the most effective long-term treatment option for patients with obesity.
However, weight regain is considered to be part of the natural history of any intentional weight loss effort. Its causes appear to be multifactorial and overlapping, and can be divided into: Patient-specific causes: psychiatric disorders, physical inactivity, medication that causes weight gain, endocrinopathies and hormonal imbalance, non-compliance and eating disorders.Operation-specific causes: choice of the bariatric surgical procedure performed, inherent limitations of the operation, technical competence of the surgeon, anatomical changes due to the operation, duration of postoperative follow-up and physiologic adaptation after surgery.
When approaching weight regain, it is essential to perform a detailed history of the patient, including: pre-surgical status (initial weight, comorbidities), type of bariatric surgery performed, weight loss trajectory (including nadir weight and time interval for the weight regain), dietary history and medication taken by the patient. Afterwards, a radiological evaluation including upper-GI contrast studies, CT scan and volumetric studies can also offer valuable information, as well as an endoscopic evaluation.
The management of weight regain has to be performed by a multidisciplinary team, and needs to include counseling about lifestyle changes and dietary manipulations, adjunct medications (anorexic agents) and, in some cases, when all the other options have failed, surgical interventions such as conversions or revisions have to be taken into account.
It is important to understand that weight loss after a surgical reintervention is usually less than with the primary operation, and also that surgical reinterventions are associated with increased morbidity and mortality. The different technical options include:
- Sleeve failure:
- The natural process is a slow dilation of the tube, that may be avoided using non-adjustable gastric bandings.
- Some patients develop de novo or worsening of preexisting GERD.
- Technical options include conversion to gastric bypass to treat GERD, as well as conversion to several malabsorptive procedures to treat either cases of insufficient weight loss or weight regain.
- Other options include endoscopic revisional treatments.
- Gastric bypass failure:
- In most cases it is due to increases in the size of the pouch which results in decreased restriction.
- Technical options include distalisation, conversion to other malabsorptive procedures, using in some cases bandings.
- Other options include endoscopic revisional treatments.
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