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A/Prof Michael Talbot hosted our latest webinar on the topic of weight regain after gastric sleeve or bariatric surgery. Here are some of the questions that he answered during the live Q&A that followed the short presentation.
What would be the revision surgery for a gastric bypass?
The type of revision surgery needed depends on several factors, including the type of bypass performed, the size of the stomach, and whether it has stretched over time.
If a patient’s stomach has stretched significantly after a bypass, it can often be trimmed and tightened. In these cases, a surgeon may also consider placing a ring around the stomach to prevent future stretching. However if the stomach has not stretched, a different procedure may be required. A bypass distalisation is also an option.
Before determining the best approach, a thorough assessment is needed. This typically includes a couple of scans and a dietary evaluation. If the patient has a small stomach but is engaging in frequent eating, surgery may not be the most effective solution.
Is there more risk in undergoing a different surgery after a sleeve?
Yes, any revision surgery after a sleeve gastrectomy is at least three times riskier than the initial sleeve procedure. This is primarily because the surgery may involve re-stapling along the existing staple line, which is technically more challenging and increases potential complications.
The risk of infection, for example, rises from approximately 1 in 500 for the first sleeve surgery, to around 1 in 50 – 1 in 100 for a revision procedure. The specific approach taken depends on the patient’s individual issues and needs.
If we notice weight gain coming on, what’s the first course of action?
The first step is to go back to basics. Focus on increasing your protein intake and incorporating more exercise into your routine. Consider using meal replacements like Optifast for around five meals a week.
It’s also important to book an appointment with the team for support and guidance. If you’ve already made these adjustments and they aren’t working, we often recommend a weight loss medication program. A structured 3 – 6 month course can help patients get back on track, and many can stop the medication once they regain control without the weight returning.
If the weight gain is significant and these simpler strategies aren’t effective, we may explore other therapies, including assessing the size of the stomach to determine if further intervention is needed.
Do you require health insurance for a revision (re-do) surgery?
Health insurance is required for nearly all weight loss surgeries, including revision procedures. While some bariatric surgeries are performed in the public system, access is extremely limited. At St George Hospital, we perform around 20 cases per year in the public system, compared to approx 1,200 in the private hospital.
In NSW, only about 2.5% of bariatric surgeries are done in public hospitals, meaning most patients will need either private health insurance or to self-fund their procedure. Health insurance is generally the more cost-effective option.
Is there a higher chance of ulcers and hernias with a gastric bypass?
Yes, ulcers are more common after a gastric bypass compared to other procedures like the sleeve or SADI. They are usually caused by factors such as aspirin, anti-inflammatory medications, smoking, or alcohol consumption. So if you’re a smoker, a bypass might not be the right option for you. However, ulcers can also develop due to bad luck, high stress, or following another operation.
As for hernias, anyone who loses a significant amount of weight is at a higher risk of developing symptomatic hernias. This is because hernias are often plugged with fatty tissue, and when that fat is lost, the hernia can loosen and become problematic. Additionally, in about 3% of cases the small bowel can twist around itself, which requires surgery to correct.
Is stomach stretching as big of an issue as once thought?
For most people, stomach stretching isn’t a major issue. However in a small number of cases it can be. When comparing stomach sizes between those who have lost weight and those who haven’t, the size is generally similar.
That said, if a patient reports feeling a lack of restriction, their stomach may have stretched slightly over time. In these cases, tightening the stomach can help restore that feeling of restriction, which can be beneficial.
Assessing stomach size is just one of many tools available when considering treatment options. Some stomachs naturally stretch more than others, though the reasons for this aren’t fully understood. This is why evaluating stomach size can be useful, especially if a patient is experiencing significant issues.
Why can individuals who have undergone bariatric surgery successfully discontinue weight loss medications without regaining weight, while those without surgery are more likely to experience weight relapse?
After bariatric surgery, the stomach can no longer produce the same range of appetite-stimulating hormones as it did before. This means that the surgical effect remains permanent, helping to regulate appetite long-term.
However, some patients go through difficult periods where they experience sudden weight regain over six months or so. This isn’t usually due to changes in their stomach but rather life events that impact their behaviour and eating habits. In these cases, using WLM (Weight Loss Medication) can help patients lose the regained weight and return to their previous habits, allowing them to maintain their results.
For people without surgery, weight loss often leads to increasing hunger over time. Once they stop WLM, their hunger returns, making it much harder to maintain weight loss. This is where bariatric surgery provides an advantage – it helps regulate hunger, making long-term weight management more achievable.
What if you’ve lost 20% with surgery but can’t lose any more weight, even with exercise?
In this case, it might be related to your metabolism. A metabolic rate analysis can help determine how much energy your body uses at rest. This information can give insights into how your metabolism is functioning and whether it’s impacting your ability to lose more weight.
If you’ve lost a significant amount of weight and still need to lose more, considering Weight Loss Medication (WLM) could be a good option. It can help speed up the process and might help you lose an additional 10-12%. Typically, people tend to lose 8-10% of their body weight within 6-9 months, and that’s often all they need to get back on track.
Start with WLM to see if it works for you. If it doesn’t, or if it’s not the right fit, we can then look into further tests to understand what’s going on.
How long can you use Weight Loss Medications (WLM)?
Weight loss medications can be used long-term, with many studies showing that they are safe and effective for use over extended periods, including 2 years or more. However, the challenge with long-term use is the cost, as they can become relatively expensive.
It’s worth testing de-escalation strategies, such as reducing the dose or using intermittent dosing to lower the cost. Increasing exercise can also help boost your metabolic rate and complement the medication. Medically, it’s safe to use these medications long-term, but it’s helpful to explore ways to manage the financial burden while still achieving effective results.
If a GP says the drugs won’t work if you don’t have any appetite, is that true?
This is often the case. If you don’t have much of an appetite and are still struggling to lose weight, it could indicate other factors at play, such as unacknowledged snacking or a metabolic rate issue. However even in these situations, it’s still worth trying the medications because they do more than just suppress appetite.
They can help reduce your overall interest in food, which allows you to unconsciously eat less. Additionally, they alter the way your body uses glucose, which can further support weight loss.
How soon post-surgery would you recommend weight loss medications?
The timing of introducing weight loss medications (WLM) post-surgery depends on several factors including the type of surgery, the amount of weight lost, and individual progress. A key concept in weight loss surgery and in weight loss treatment in general, is that you can predict how much weight someone will lose based on their initial progress in the first 3 to 4 months.
For example, with sleeve gastrectomy, the goal is usually for patients to lose about 30% of their total body weight. A target of 15% weight loss should occur in the first 3 to 4 months. If the patient has not reached 15% by that point, it may suggest they may not achieve their full weight loss goal, and WLM could be considered at that time.
For most patients, the first 12 to 18 months post-surgery is the key window for weight loss. If progress slows down significantly or a plateau persists, introducing medications may be appropriate to support further weight loss.
In cases of revision surgery such as switching from sleeve to bypass, weight loss may take longer to achieve so it might be reasonable to consider starting WLM earlier, once the patient is on normal food.
Should I go to my GP for weight loss medication (WLM) or UGIS?
It depends on your GP. Dr Jenny Matthei is a General Practitioner (GP) with a specialist interest who has retrained as a weight loss physician and focuses solely on weight loss management. She is happy to supervise patients through the process.
However, many GP’s are generalists and may feel less confident managing patients who are using weight loss medications. It’s often a good idea to start by consulting your GP, but if they are not comfortable with or interested in this approach, you can always make an appointment with Jenny.
A common pitfall when using WLM with your GP is that without the proper diet and lifestyle plan, you may not reach your weight loss goals for several reasons. First, if you use WLM without a high-quality diet, you may lose protein and muscle mass along with fat. This can contribute to increased fatigue, which can be even worse if you’re not eating the right vitamins and nutrients. Losing muscle mass also lowers your metabolic rate.
For the best results, it’s crucial to combine WLM with the right diet and exercise plan to maximise your success. GP’s often don’t have the resources to provide all of these components, but at UGIS we offer everything in one place, with Jenny providing the necessary prescriptions as well as guidance on diet and exercise.
Can the stomach “bounce back”?
The size of your stomach doesn’t change if you don’t eat. Resetting your stomach size, going on a diet, or taking weight loss medications (WLM) won’t change how much your stomach can hold. However, what you eat can change how much you eat.
When patients experience weight regain after bariatric surgery, they often report being able to eat large portions of certain foods, like macaroni and cheese, but feeling full quickly with healthier options like salad or vegetables. The key is changing what you eat, rather than focusing on the stomach size itself.
By introducing meal replacements or using WLM, you can modify your food choices. High-protein, low-sugar foods can help suppress appetite, while sugary, high-energy foods can stimulate hunger. GLP-1 agonists, a type of WLM, help reduce cravings for sugar and carbs, which are often the foods that trigger hunger. This approach can help re-establish healthier eating habits and better appetite control.
When will the price of weight loss medication (WLM) come down?
The price of WLM is unlikely to decrease significantly for at least five years. Currently there seems to be a bit of a double standard, as diabetics can access GLP 1 agonists for free and the “wholesale price” is low, while those seeking it for weight loss must pay more.
It will likely take around five years before GLP-1 agonists come off patent and become available for generic production, which could help reduce prices. Additionally, with only two options currently available on the market and the demand being so high, the companies have little incentive to lower prices. However as we’ve seen with other expensive medications in the past, once more companies enter the market, the prices will eventually come down in order to capture a share of the market. Still, it will likely take a minimum of five years for prices to drop.
How do you increase metabolism in someone who physically can’t exercise?
Increasing metabolism without exercise is quite challenging, but it can be done by making dietary adjustments. The key is to switch from foods that drive insulin production to those that don’t. Foods that require more effort to metabolise can help increase energy burn.
It’s also worthwhile to assess the individual’s metabolic rate, which can be measured to understand how many calories they burn while at rest. Once you know the baseline, you can tailor their diet to suit their metabolism, ensuring that they are consuming foods that support their more efficient metabolism.
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