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36 Causes ofWeight Regain After Duodenal Switch andIts Derivatives
335
or 40kg/m2 has also been used as a denition for weight recidivism and is shown to
be associated with patient satisfaction after classic DS [35]. Given the low numbers
of DS procedures performed worldwide, there is paucity of quality data on the incidence of long-term weight loss failure and regain after classic DS procedure.
In the 16-year case series by Hess etal., among 167 patients with ≥10years of
follow-up after surgery (92% follow-up rate of eligible patients), only 6% had unsatisfactory weight loss with <50% EWL long-term after classic DS [19]. The patients
with unsatisfactory weight loss underwent revisional surgeries that included either
common channel limb shortening or re-sleeve especially early in their experience
when the gastric sleeves were made very large. Surprisingly, the weight loss after
shortening of the common channel was unsatisfactory, as none of the patients lost
>9kg extra but did not regain any further weight. On the contrary, in the early group
of primary operations when the sleeve was constructed larger, all patients that
underwent a re-sleeve procedure had a subsequent effective weight loss [19].
Furthermore, in a 20-year comprehensive account of consecutive DS procedures in
2615 patients (847 with 10+ years of follow-up; 94% of the eligible patients),
Marceau etal. describe that after a mean follow-up time of 7.3 years and up to
15 years, 8% of patients with an initial BMI ≤ 50 kg/m2 did not achieve a
BMI<35kg/m2 vs. 17% of those with severe obesity at baseline (BMI>50kg/m2)
who did not obtain a BMI<40kg/m2 [12]. However, repeat/revisional surgery for
insufcient weight loss or weight regain was only necessary in 41 patients (1.6%)
and consisted of further shortening the common channel length in 23 patients and
re-sleeve in 18 individuals [12]. Finally, in another case series, Sethi etal. report on
long-term outcomes of 100 patients who underwent biliopancreatic diversion and
classic DS (64%) at their center [14]. At a mean follow-up time of 8.2years with
72% retention at 10+ years (56 of 78 eligible), they observed an overall 8% weight
loss failure rate observed 6.2 after surgery. This estimate was 13% among the group
of patients with at least 10+ years of follow-up, but the authors do not offer any denition for what constituted weight loss failure, report no statistics for weight regain,
and do not specify the distribution of the two procedures among the patients with
10+ years of follow-up [14].
Based on the available literature with 10+ year reported outcomes after classic
DS procedure, the long-term incidence of weight regain is quite low (1.6–8%). This
estimate is considerably lower than the respective long-term incidences of weight
recidivism after SG and RYGB as the two most commonly performed bariatric procedures worldwide. Long-term (7+ years) incidence of weight regain after SG is
shown to be 14–37% (13% requiring revisional surgery) and 8–20% after RYGB
(3–6years after surgery) [8, 36].
36.3.2 Single Anastomosis DS Derivatives
As mentioned above, long-term outcomes after SADS derivatives are scant.
Overwhelming majority of the case series and cohorts are reported after 2018 and
mainly include short- to medium-term outcomes after surgery which makes
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assessment of weight regain, an entity that is highly dependent on time since surgery, even more difcult [15, 25, 36].
In a recent study from Spain, Finno etal. retrospectively described their institutional outcomes of 181 patients that underwent SADI over a 4-year period compared to 259 that had classic DS but over a 12-year period [37]. In the SADI arm,
over a mean follow-up time of 27months after surgery, 5/181 patients needed
conversions to a classic DS conguration. But only two of these patients (1.1%)
underwent the revision to DS for inadequate weight loss, and there were no
patients with reported weight regain [37]. However, the authors neither dened
what constituted inadequate weight loss nor reported the efcacy of the conversion to DS in terms of weight loss [37]. Also, in their report of the rst 100 patients
who had SADI at their pioneering institution, Sanchez-Pernaute etal. describe a
1% rate of weight regain up to 5years after surgery in a patient who originally
achieved a 63% EWL 10months after SADI but regained the weight up to an
EWL>50% by the end of the follow-up period [38]. Finally, in another recent
prospective cohort study comparing SADI (N=42) to classic DS (N=20), at a
median follow-up time less than 2years, only 1/42 (2.4%) SADI patients had
inadequate weight loss (51% EWL and BMI still> 40kg/m2) after a previous
failed SG and underwent a conversion to classic DS [21]. Prior to SG, the patient
suffered from extreme obesity with a BMI of 63kg/m2, and over the 8months
subsequent to the conversion of SADI to DS, the patient went on to lose an additional 15kg in absolute weight and achieved a 63% EWL as of the last available
follow-up [21].
Given the promising short- to medium-term outcomes that also seem to be comparable to classic DS and superior to RYGB coupled with continued calls for further
quality studies by major international bariatric societies [2, 15, 21, 25], we can
expect to have a better understanding of such statistics like weight regain/recidivism
after SADS in the coming years. At medium-term follow-up, insufcient weight
loss and weight regain after SADS derivatives are rare occurrences similar to classic
DS and <10%. Moreover, in the current era of bariatric surgery, the need for safe
and effective revisional surgeries is on the rise, especially after failed SGs and
mainly in patients with severe obesity, so SADS procedures have a role. Single
anastomosis DS derivatives also allow for a “three-step” approach (SG → SADI →
DS) if needed, in the surgical treatment of obesity and related comorbidities especially in patients who suffer from extreme obesity (BMI≥60kg/m2).
36.4 Causes ofWeight Regain
36.4.1 Lifestyle andPatient-Related Factors
The cause of weight regain/recidivism after DS-type procedures is multifactorial, as
is the case after all other types of bariatric surgery. Poor lifestyle habits and other
patient-related factors are among the primary reasons for weight regain especially
long-term after any bariatric surgery and require a multidisciplinary approach
36 Causes ofWeight Regain After Duodenal Switch andIts Derivatives
337
[39–41]. Sedentary lifestyle and poor level of activity/exercise along with binge
eating disorders, grazing, lack of impulse control, emotional eating, anxiety, and
depression are among the most commonly cited lifestyle and patient-related factors
associated with weight regain after bariatric surgery [42–44]. The signicant negative association of such behavioral and psychological patient-related factors with
weight regain after bariatric surgery has been more recently emphasized in light of
the unfavorable impact from the coronavirus disease 2019 pandemic especially with
the ensuing self-isolation and lower level of activity [45, 46].
In a recent systematic review by Athanasiadis et al. that included 32 studies
involving 7391 RYGB and 5872 SG patients, regain of at least 10% of weight lost
was observed to be 18%, and the authors reported that risk factors for weight regain
fall in ve main categories [47]. These categories included anatomical (surgical),
genetic, dietary, psychiatric, and temporal factors. Among lifestyle and patientrelated factors, anxiety, sweet consumption, emotional eating, portion size, food
urges, binge eating, loss of control/disinhibition when eating, and genetics along
with some surgical factors including gastrojejunal stoma diameter, gastric volume
after SG, and time after surgery were found to be positively associated with weight
regain after surgery [47]. This systematic review again highlights that the underlying factors that lead to weight regain after any bariatric surgery are multifactorial
and require a systematic and multidisciplinary approach to address them.
36.4.2 Surgery-Related Factors
Given the multifactorial nature of weight recidivism after surgery, anatomical factors that could contribute to weight regain after DS-type procedures should also be
considered and ruled out. Potential surgical targets in DS-type procedures either
involve its restrictive SG component or the duodeno-ileal bypass component, i.e.,
the length of the common channel. To assess the SG component of DS-type procedures, investigations should include an upper gastrointestinal study or a sleeve volumetric study along with an upper endoscopy to rule out a grossly dilated sleeve or a
poorly constructed SG with retained fundus. If present, these factors may contribute
to inadequate weight loss or weight regain after surgery and can be a target for revisional re-sleeve surgery [19, 48–50].
Another potential surgical target to address weight regain after DS-type procedures
would be to shorten the common channel. In classic DS, the common channel is already
very short (100cm), and given the hypo-absorptive nature of this procedure, patients are
at a higher risk of developing long-term nutritional deciencies especially fat-soluble
vitamins, micronutrients, and protein-calorie malnutrition [13, 14]. Therefore, shortening
the common channel further may risk exposing these patients to signicant undesired
malnutrition and at a very limited added benet in terms of weight loss [19]. However, in
case of SADS derivatives, common channel length is longer (250–300cm) and theoretically amenable to further safe shortening. Thus, as previously mentioned, SADS derivatives allow for a step-up approach (SG→SADI→DS) especially for patients who suffer
from extreme obesity [21, 37].
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36.5 Summary
Despite having long-term data (≥10years) after classic DS procedures, the information on long-term outcomes after its single anastomosis derivatives is still lacking,
and these procedures remain less prevalent compared to SG and RYGB.Moreover,
both primary weight loss failure and weight regain are not uniformly dened in the
literature. The lack of consensus around the denition of weight regain coupled with
limited prospective literature on long-term outcomes after DS-type procedures negatively impacts the conclusions drawn on this topic. However, based on the available data, the incidence of weight regain requiring a surgical intervention long-term
after classic DS procedure is quite low (≤10%). Based on the current literature and
up to medium-term follow-up, this statistic is also similar for the single anastomosis
derivatives. The low incidence of reported weight regain after DS-type surgeries is
not surprising given that these hypo-absorptive procedures are often considered the
ultimate bariatric/metabolic salvage operations after other previous surgeries have
resulted in weight recidivism and refractory metabolic comorbidities. As for causes
of weight regain after DS-type procedures, similar to other types of bariatric surgery, the occurrence is considered multifactorial and associated with various patientrelated, lifestyle, and surgical factors that require a multidisciplinary approach.
Single anastomosis DS derivatives allow for a “three-step” approach
(SG→SADS→DS), especially in those patients who suffer from extreme obesity.
This step-up approach may be an option when the previous surgical step is faced
with either inadequate weight loss or weight recidivism along with refractory
comorbidities. Finally, there is a real need for more prospective studies including
randomized controlled trials with long-term outcomes to further establish the support for the single anastomosis DS-type procedures.
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Chapter 37
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Revisional Surgery forWeight Regain
SaraArdila, NathanZundel, andMuhammadGhanem
37.1 Introduction
Morbid obesity is a global chronic disease affecting 13% of people worldwide [1].
Weight loss surgery has been proven to be effective in addressing this chronic disease and its associated comorbidities. In 2016, over 200,000 procedures were performed in the United States, and the volume continues to grow [2]. Cases analyzed
between 2015 and 2018 indicate an overall growth rate of 21.9% [3]. The most
common surgeries performed in the United States are Roux-en-Y gastric bypass
(RYGB), sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal
switch (BPD/DS). Estimated mean weight loss is 33% of the initial body weight [4].
Unfortunately, it is estimated that up to 25% of patients will have weight regain after
primary surgery [5]. Weight regain or recidivism has emerged as a clinical entity
and important public health issue given its association with re-emergence of obesityrelated comorbidities, worsening quality of life, and increased healthcare costs.
With the increased number of primary bariatric surgery performed worldwide, revisional surgery has also increased, and it has been shown to be the fastest-growing
category of bariatric procedures, currently representing 7 to 15% of all bariatric
operations [6]. Long-term rates of revisional surgery have been estimated to be as
high as 56% [7]. In this chapter, we will focus on the incidence of weight regain, its
denition, and revisional surgery to address it.
S. Ardila · M. Ghanem (*)
Orlando Health Weight Loss and Bariatric Surgery Institute, Orlando Regional Medical
Center, Orlando, FL, USA
e-mail: sara.ardila@orlandohealth.com; Muhammad.ghanem@orlandohealth.com
N. Zundel
Jackson North Medical Center, Miami, FL, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_37
343
344
S. Ardila et al.
37.2 Incidence andCauses ofWeight Regain
Weight regain is estimated in up to 25% of patients following primary bariatric
surgery [5]. The incidence of weight regain varies per index procedure (Table37.1).
In a single-center retrospective review of 534 patients, 64% sought revisional surgery for weight regain [3]. In addition, it is estimated that more than 80% of the
weight regain happens within the rst 6years following primary surgery. A major
factor contributing to weight regain is lack of adherence to recommended followup visits, observed in approximately 60% of patients 4years after primary surgery [4].
The etiology of weight regain has been attributed to: [4, 11]
• Noncompliance with dietary recommendations.
• Hormonal/metabolic imbalance.
• Mental health.
• Physical inactivity.
• Anatomic/surgical factors.
• Medications.
Table 37.1 Estimated
incidence of weight regain
per primary bariatric
surgery
Procedure Incidence (%)
Adjustable gastric band 33.3–40
Vertical banded gastroplasty 26–74
Sleeve gastrectomy 5–25
Roux-en-Y gastric bypass 10–34
Duodenal switch 10
Data from Refs. [8–10]
37 Revisional Surgery forWeight Regain
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37.3 Denition ofWeight Regain
Dening weight regain has been a challenge. There is no clear denition or guideline established. Multiple groups have attempted to dene weight regain. A systematic review and meta-analysis found that the most common denition is excess
weight loss (EWL) less than 50% within 18–24months after the primary operation.
Weight regain/recidivism has been dened as [12]:
• EWL less than 50% from the original preoperative weight (most common).
• BMI>35kg/m2 or EWL<50%.
• BMI>30kg/m2 or 35 accompanied by EWL<50%.
• Increase in BMI>5kg/m2 compared with preoperative weight.
• Total body weight loss (TBWL)<25%.
• Weight regain>30% of lowest post-surgery weight.
One of the current challenges in the management of weight regain is its early
recognition and subsequent intervention. Istfan etal. aimed to establish a guideline
for the early recognition of weight gain. Based on their 11-year follow-up data from
a multiethnic bariatric patient population, they dened weight regain according to
the rate of increase in weight relative to nadir weight per 30-day interval [4]. They
classied weight regain as mild, moderate, and rapid as weight regain/nadir of 0.2%
to <0.5%, 0.5% to 1%, and >1% per 30-day interval, respectively.
37.4 Preoperative Evaluation
A multidisciplinary evaluation is essential prior to recommending revisional surgery to patients presenting with weight gain. As with primary surgery, a nutritional
evaluation, behavioral/psychological assessment, and endoscopic and contrast
series studies should be obtained. The latter will not only aid in establishing an
anatomic etiology for weight regain if present, but it will also aid in choosing the
type of revisional surgery [6].
37.5 Selecting theType ofRevisional Surgery
There are several revisional procedures following primary bariatric surgery. The
choice of revisional surgery is tailored according to initial surgery (Table 37.2),
cause of failure, and surgeon’s experience. Multiple revisional surgeries have been
described for all primary bariatric surgeries, but no standardized guidelines have
been established.
In June 2019, 70 experts from 27 countries formed a committee and created the
rst consensus on revisional bariatric surgery. An agreement of 70% or more was
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