Weight Regain Clinic helps patients maintain weight loss after bariatric surgery

A majority of patients who undergo Roux-en-Y gastric bypass (RYGB) achieve substantial weight loss as well as resolution of diabetes and other comorbidities. Unfortunately, post-surgical weight gain remains a common problem. Weight loss usually reaches a maximum 18 months after surgery, with varying amounts of weight regain occurring over the next several years.

"Studies have shown that significant weight gain occurs in about one-third of patients after reaching their nadir weight following RYGB. This is especially problematic in those with metabolic or cardiovascular disease, and it definitely affects quality of life," says Barham K. Abu Dayyeh, M.D., a specialist in bariatric endoscopy at Mayo Clinic's campus in Rochester, Minnesota.

Although the exact etiology of weight regain isn't well-understood, it is clearly multifactorial. Psychological and behavioral issues, nutritional habits, genetic background, physical activity, and time from surgery are all risk factors. In addition, decreased satiety can occur with dilation of the gastrojejunal (GJ) stoma (the connection between the gastric pouch and jejunum), pointing to an interplay between behavioral factors and anatomy.

Increased GJ stoma diameter linked to weight regain

In Roux-en-Y gastric bypass, the stomach is divided into an upper gastric pouch and a lower gastric remnant. The jejunum is also divided, and the gastric pouch connected to the jejunum for the GJ stoma, which ideally measures 1 centimeter in diameter.

In a study by Dr. Abu Dayyeh and colleagues that appeared in the March 2011 issue of Clinical Gastroenterology and Hepatology, greater GJ stoma diameter was associated with postoperative weight gain. Further, the amount of regained weight was directly proportional to the increased stoma diameter. Just what causes gastrojejunal anastomosis dilation isn't entirely clear, however.

"The dilated stoma may be a surrogate for a compliant gastric pouch, which allows larger meals," Dr. Abu Dayyeh says. "Whatever the reason, for the first few years, people seem to eat relatively small meals, but over time, they start eating more and lose the satiety response experienced immediately after RYGB."

Addressing post-surgical weight regain

People with substantial weight regain after gastric bypass surgery once had few options. Revisional bariatric surgery procedures to address pouch size and gastrojejunal stoma dilation are problematic, with complication rates approaching 15 percent in some cases. But now, endoscopic interventions such as suturing to reduce GJ stoma size appear to be effective and well-tolerated, with few complications.

To provide bariatric surgery patients with more effective and supportive postoperative care, Mayo is establishing a multidisciplinary Weight Regain Clinic, which will offer behavioral, nutritional, surgical and endoscopic interventions to patients experiencing weight regain.

"On referral, each patient meets with an endocrinologist, a psychologist specializing in behavior modification and a registered dietitian," Dr. Abu Dayyeh explains. "The psychologist looks for issues such as emotional or binge eating and substance abuse, and the endocrinologist and dietitian address available medical treatments and diet.

"Once we've received these evaluations, we order an upper GI series to look for gastrogastric fistula, a complication of RYGB in a small percentage of patients, and endoscopy to identify stoma dilation. If either of these is found, the patient is referred for surgical repair of the fistula or endoscopic suturing to reduce stoma size to less than 1 centimeter — about 8 millimeters."

Dr. Abu Dayyeh says patients then receive more behavior therapy and nutritional counseling. "Because of the large number of patients undergoing bariatric surgery, the demand for therapy to address weight regain will only increase. An integrated multidisciplinary approach gives them the maximum chance," he notes.

For more information

Abu Dayyeh BK, et al. Gastrojejunal stoma diameter predicts weight regain after Roux-en-Y gastric bypass. Clinical Gastroenterology and Hepatology. 2011;9:228.