The Sleeve Gastrectomy and How and Why it can Fail (Surgery Current Research 2014 publication)

[Escape_Pod 358]

Abstract

Long-term weight regain is a fearedcomplicationof restrictive bariatric operation. The Sleeve Gastrectomy (SG)

is still in its early stages as a primary bariatric surgery and long-term data about its efficacy remains limited. From the

long term studies available it seems that approximately one-fifth of SG patients might be at risk for long-term weight

regain and about 5-10% of total SG patients will require surgical management forit. The possible mechanism behind

this weight regain is slowly being addressed. Patient noncompliance with dietary and lifestyle regimens is the most

practical factor that needs to be considered and can be prevented with a multidisciplinary team. Long-term gastric

pouch dilatation and gut hormone modulation are other theories that have been proposed to explain this weight regain.

Successful management strategies to combat weight recidivism include revisional bariatric surgery, performing a resleeve

gastrectomy or the addition of an adjustable band in the primary banded sleeve gastrectomy. However, the

safety of revisional bariatric surgery is a concern and should be performed only by an experienced bariatric surgeon.

It remains that as the SG continues to grow as a popular choice for the management of morbid obesity, more concrete

long term information will become available to address the how and why weight regain occurs.

http://omicsonline.org/open-access/the-sleeve-gastrectomy-and-how-and-why-it-can-fail-2161-1076-4-180.pdf

[PdxMan 4,292]

Interesting article. Basically supports what my thinking has been. I just wonder how long does the procedure have to be done before it is no longer referred to being "in it's infancy"? They state numbers referring to patients 6 years out, so, that would appear to me to be out of it's infancy ...

But, I reached goal 8 months post and have been maintaining the same weight for over 2 years now. In the article, they state "failure" of a procedure if you have regained 22 pounds or more. That seems like a heavy statement because I have read on here many folks who have regained this and more, but were able to lose it again when they recommitted to comply with the basic guidelines. To me, that is not a procedural failure, but rather an issue with the patient's compliance. As far as why there is weight gain, the article states:

Theories to explain weight recidivism following SG

The most practical and first consideration that needs to be

addressed in a patient presenting with weight recidivism is adherence

to dietary and lifestyle regimens as outlined by the multidisciplinary

team [15]. Modifiable risk factors for failure after SG include a lack of

physical activity, a lack of change of nutritional behavior, and a lack of

follow-up [11]. The importance of proper nutritional counseling after

bariatric surgery has been supported by the literature. A significant

positive association has been shown between patient vigilance with

maintaining food records and weight loss; while on the other hand,

there is a significant negative association between nutritional counseling

attendance and weight gain [16,17]. Furthermore, Himpens et al.

showed that craving for sweet eating tends to increase the further out

from SG surgery [18]. SG is not a malabsorptive procedure therefore

any high calorie junk foods will be readily absorbed, leading to potential

significant weight gain. This patient “cheating” must be an important

first consideration when assessing for contributing factors leading to SG failure [19]. Psychological factors also need to be addressed

in a patient first presenting with weight re-gain, as there is a marked

correlation between weight-regain and psychiatric co-morbidities [20].

The weight wise clinic in Edmonton, Alberta Canada, is a model for a

multidisciplinary clinic where patients are followed post-operatively to

ensure maximum compliance and behavioral modification [4].

There have been so many pissing matches on this forum with regards to the "cheating" question. I'm not going to get into that battle again. Just be ready to accept the consequences. It is difficult for me to support an alcoholic who won't stop drinking ...

Bottom line, IMO, is that if I were to gain 30 pounds, it will be due to my "cheating" the sleeve, not the failure of the procedure. I also believe that if I were to return to rigorously following the guidelines, I would drop that 30 pounds. Does this point to a failure of the procedure?

Edited April 2, 2014 by PdxMan

[Rebellious Butterfly 91]

Intresting

[Lynne1029 61]

This definitely makes you think...

Thank you

[Mrs.RRn 2,111]

Failure of the patient vs failure of the sleeve??? Hmmm....

[PdxMan 4,292]

I don't know if I would go so far as to say failure of the patient in as much as I would say failure for the patient to fully understand the consequences of what they were doing. Failure to set reasonable expectations, as I often chime in about.

So many times I see people posting their disappointments with their weight loss. They lose a pound every few days and then when that slows down, they throw their hands in the air screaming, "What am I doing wrong!!??" Then, they get a case of the fucked-its and "cheat".

I think everyone goes into this with the best of intentions. Not everybody is doing this to get skinny. They just want to lose enough weight to get off medications or the like. They aren't interested in exercising and putting in the effort to cook nutritionally balanced meals. I applaud those folks. They set their expectations based on what they knew they wanted and were capable of.

The folks who do have expectations of getting skinny need to really examine what work they are willing to do to meet that expectation before having the surgery. Those who have had the procedure know this is not a magic bullet. I was devastated at first mourning the loss of food as my comfort mechanism. I had no idea it would hit me as hard as it did. For me, it was the fact I am also part of a 12 step program dealing with addiction that I was able to address these and learn.

Now understand, these are my truths and may or may not be anybody else's. But one of the reasons I come to this forum and stay here to share my experience, strength and hope is because it is a constant reminder of where I came from. I am my own worst enemy. Self knowledge does not prevent self sabotage.

Edited April 2, 2014 by PdxMan

[Escape_Pod 358]

I'll admit up front, if regain of 22 pounds is the failure line, then I'm a failure. Or, I should say, I was. I'm working to get it back off again, and am well below that line again. But I definitely slipped back into old habits, and found myself slipping rapidly down the frightening slope back to obesity.

I don't find it useful to assign blame, either to the patient, or to the procedure, mostly because I think most of us were blamed for our obesity as pre-ops for a failure to "just stop" eating junk and get more exercise. Some of us struggle just as much to change what and how much we eat as post-ops (long-term).

I think it matters less whose failure that is, and more that we figure out how better to support patients, before and after surgery, in making whatever changes are needed for the individual to sustain long-term weight loss. There's so much at play here - long-ingrained habits, emotional and psychological elements, hormonal and biochemical elements, physical limitations, societal expectations... it's complicated.

I'm glad to see some honest reporting, though, on "failure" rates. For many (most?) of us, keeping those XX pounds off "forever" is going to require huge changes in many areas of our lives, not simply eating what we always have in smaller portions.

[Seela 1,187]

Personally I'm sick of hearing about how the surgery failed. I'm sure it does happen once in a while but honestly most of the time when I see someone that's had great success with wls then "failed" it's because they just stopped following their plan. Plain and simple. As a hairstylist I see a lot of women that have had wls, mostly bypass, and probably 75% of them have major regain about 4 years later. They ALL have the exact same thing in common. .. they have all given up on their eating plan and exercise. It seems simple to me (simple in theory not practice)... stay on your plan and remain successful. I think it is entirely unfair to say the surgery or procedure is a failure when if one "simply" (lol) continues to follow their plan it would not fail. We all are told in the beginning that this surgery requires a lifelong commitment and if we choose not to abide by those guidelines then the surgery has NOT failed, the patient has. I'm only just over 5 months out and I can already see how difficult it will be in the future, but if I end up regaining my weight (which I won't ) I will have nothing to blame but myself.

[Escape_Pod 358]

Yep, and most of us were obese as pre-ops because we failed to follow the "simple" guidelines of eat less / move more. And society judged us for failing to have a little self-discipline and lose the weight without surgery. Or, we went on a restrictive diet, became exercise fanatics, and lost a ton of weight, all the while committed to a permanent lifestyle change and then failed to "simply" stick with it and regained. Any of this sound familiar? How is it different to judge post-ops for failing to follow the plan?

I just don't think assigning blame is useful in this discussion, regardless of which way the finger is pointing, even if you're pointing it at yourself.

[Madam Reverie 2,958]

Fascinating... 1 in 14 had dilation (that's a low figure on balance)

And physical ghrelin compensation should be considered....

That's the little beast that makes us hungry. Ergo, there are cerebral and hormonal checks and balances which potentially need to come into play more heavily to ensure, along with dietry compliance, that we stay on the straight and narrow.

I'll be honest. I'm 6 months out and I am hungry. I was not one of the lucky ones whose appetite disappeared. I cannot eat a huge amount in one sitting, but I can surely graze regularly. I'm not saying I'm chowing down on horrendous things either, but I can absolutely state that at 5 months, my capacity to eat went up considerably and I see, personally, that I'm going to have to really work at this - for life. Its almost like its the same beast which beat me up daily before the surgery.

i concur with the statements in the report. I would also advocate they channel the research funding into working out how to combat the ghrelin and physical compensatory mechanism. After all, it is well proven that someone who loses their sight, often get acute hearing abilities.

This is where I feel the weakness in this procedure, for the majority of us and due to the fact that for most, follow-up care is minimal, lies.

Scary stuff...

[PdxMan 4,292]

I think more interesting is that 1 out of 14 didn't experience weight gain, as they defined it.

Granted, it is a small sample, but it lends itself to what I also hold true. I am not stretching my sleeve out, and if it were to be larger than it was in the few months post op, it is by no means responsible for any weight I gain. I guess I will have to blame it on the fork if I should begin to gain.

Fascinating... 1 in 14 had dilation (that's a low figure on balance)

[Georgia 2,908]

Interesting article. Basically supports what my thinking has been. I just wonder how long does the procedure have to be done before it is no longer referred to being "in it's infancy"? They state numbers referring to patients 6 years out, so, that would appear to me to be out of it's infancy ... But, I reached goal 8 months post and have been maintaining the same weight for over 2 years now. In the article, they state "failure" of a procedure if you have regained 22 pounds or more. That seems like a heavy statement because I have read on here many folks who have regained this and more, but were able to lose it again when they recommitted to comply with the basic guidelines. To me, that is not a procedural failure, but rather an issue with the patient's compliance. As far as why there is weight gain, the article states: There have been so many pissing matches on this forum with regards to the "cheating" question. I'm not going to get into that battle again. Just be ready to accept the consequences. It is difficult for me to support an alcoholic who won't stop drinking ... Bottom line, IMO, is that if I were to gain 30 pounds, it will be due to my "cheating" the sleeve, not the failure of the procedure. I also believe that if I were to return to rigorously following the guidelines, I would drop that 30 pounds. Does this point to a failure of the procedure?

I SOOOOO agree with you! I DID regain 27 pounds - 3 years out. Why? Cookies, candy, carbs, no exercise, yadayadayada. AND I DID lose thos 27 and an additional 10 with work and exercise and I'll tell you what - it would have been extremely difficult if I didn't have my sleeve. I Still Have the restriction and if eating properly, can only eat a small amount still. I DO get hungry sooner than Before and have to guard very carefully my calorie count per day because if I go over a certain amount I WILL and do gain.

Was my sleeve a failure? No. I feel truly successful almost four years out and 110 pounds lighter, normal BMI and size 8!

[NMJG 1,266]

Very interesting. I wish they had more data, and I wish they had data on people starting with BMIs lower than 40. Regain is my #1 fear.

[PdxMan 4,292]

Very interesting. I wish they had more data, and I wish they had data on people starting with BMIs lower than 40. Regain is my #1 fear.

IMO, I don't think starting BMI plays a factor whether if not the procedure is put in the category of a failure? (As they have defined it)I would love to know your thoughts on how this plays a role.

[Band2Sleever 78]

I agree, scary stuff indeed @@Madam Reverie

"Its almost like its the same beast which beat me up daily before the surgery" ... THAT scares me. What if I have the surgery, and a few months or years out the hunger comes back and the weight creeps back on?

I'm having the sleeve in May - it's a conversion from band, which had to be removed, and I've regained to obese BMI again