The Responsibility for a Failed Weight Loss Surgery Procedure, Part Two

July 20, 2018

Previously in my “The Responsibility for a Failed Weight Loss Surgery Procedure, Part One” article, we had an overview of the possible reasons of dissatisfaction with weight loss surgical outcomes. These were divided into the possible patient and surgical causes. We didn't get into the details of some of those possible contributing factors, but we will cover some of them in this article.

Causes of Failed Procedures in the Order of Possible Significance

Adjustable Gastric Banding

The overwhelming issue with the Adjustable Gastric Banding, both the Lap Band and The Realize Band may be the unrealistic expectations from the device. The Adjustable Gastric Band is truly only a device.

It is documented that the patients with the strictest follow-up, frequent adjustments, and the most rigid adherence to dietary instruction will do better than those who, for a number of reasons, are unable to get frequent adjustments and follow-up. This is quite frequently seen where patients come to our office with not having had any adjustment or follow-up due to cost consideration of expensive adjustment or follow-up fees.

It is important not to forget that even if the patient can afford, and sticks to the rigid structure of the Adjustable Gastric Banding, the outcome is far less desirable than that of the other surgical alternatives.

The notion that Adjustable Gastric Banding is the “least invasive” “reversible” or “simple” procedure is nothing more than a few catchphrases. The Adjustable Gastric Banding may be simple to place technically, however, it is very intensive when it comes to follow-up, both on the part of the patient and the surgeon.

 A - Activity (An integral part of any healthy lifestyle, increase metabolic rate and building muscle mass)

 C - Complication (Complication of any surgical or medical treatment, i.e., hypertension with diet pills, leak with a surgical procedure)

 D - Diet (Healthy lifelong food selection are critical to lifelong weight management)

 E  - Expectation (What patients THINK the outcome a treatment is, may significantly differ from results documented by scientific data)

 F - Follow-up (Long-term follow up with the primary treating surgeon)

 P  - Procedure (choice of the different operations)

 T - Technical (Specific variations of a particular procedure, i.e., size of the pouch in RNY, the length of the common channel in DS, or bougie size in DS)

 S - Supplements (Vitamin and mineral supplements needed)

Gastric Bypass

Until recently, Gastric Bypass was the most commonly performed weight loss surgery in the US. The failure of Gastric Bypass, excluding the ones caused by technical issues (gastro-gastric fistula, large pouch, large or dilated gastro-jejunostomy anastomosis) usually occurs many years after the surgery.

Long-term sustained weight loss is in the 50-70% range. Between 30-50% of the Gastric Bypass patients will experience weight regain.

There is also the subset of patients, who years after surgery, will continue to deal with the complication of dumping syndrome, the return of diabetes and other comorbidities even if the weight gain is not significant. Patient compliance may address some of the side effects of the surgery. Unlike what some have suggested, dumping syndrome does not protect a Gastric Bypass patient against weight regain.

 A - Activity (An integral part of any healthy lifestyle, increase metabolic rate and building muscle mass)

 C - Complication (Complication of any surgical or medical treatment, i.e., hypertension with diet pills, leak with a surgical procedure)

 D - Diet (Healthy lifelong food selection are critical to lifelong weight management)

 E  - Expectation (What patients THINK the outcome a treatment is, may significantly differ from results documented by scientific data)

 F - Follow-up (Long-term follow up with the primary treating surgeon)

 P  - Procedure (choice of the different operations)

 T - Technical (Specific variations of a particular procedure, i.e., size of the pouch in RNY, the length of the common channel in DS, or bougie size in DS)

 S - Supplements (Vitamin and mineral supplements needed)

Gastric Sleeve

The most commonly performed procedure in North America is the Gastric Sleeve. The rise of the Gastric Sleeve can be, at least in part, contributed to the high failure rate of the Adjustable Gastric Banding.

As more and more patients were dissatisfied with the Adjustable Gastric Banding, because of inadequate weight loss, weight regain or the associated complications, technically simpler alternatives have become popular.

The responsibility for weight gain after Gastric Sleeve can be placed on the surgical side for recommending the operation to a patient who will probably not do well long-term (high BMI, metabolic conditions such as diabetes or PCOS) and patients who will have to be very extremely careful with volume and food choices.

 A - Activity (An integral part of any healthy lifestyle, increase metabolic rate and building muscle mass)

 C - Complication (Complication of any surgical or medical treatment, i.e., hypertension with diet pills, leak with a surgical procedure)

 D - Diet (Healthy lifelong food selection are critical to lifelong weight management)

 E  - Expectation (What patients THINK the outcome a treatment is, may significantly differ from results documented by scientific data)

 F - Follow-up (Long-term follow up with the primary treating surgeon)

 P  - Procedure (choice of the different operations)

 T - Technical (Specific variations of a particular procedure, i.e., size of the pouch in RNY, the length of the common channel in DS, or bougie size in DS)

 S - Supplements (Vitamin and mineral supplements needed)

Duodenal Switch

Duodenal Switch is proven to be the most successful weight loss surgical procedure long-term. The responsibility of the patient is great for this procedure, for adherence to supplements and follow-up.

Patients can experience weight gain or weight loss with poor dietary choices and non-compliance with the supplements. In some patients, the requirements change over time as aging changes the nutritional requirements.

 A - Activity (An integral part of any healthy lifestyle, increase metabolic rate and building muscle mass)

 C - Complication (Complication of any surgical or medical treatment, i.e., hypertension with diet pills, leak with a surgical procedure)

 D - Diet (Healthy lifelong food selection are critical to lifelong weight management)

 E  - Expectation (What patients THINK the outcome a treatment is, may significantly differ from results documented by scientific data)

 F - Follow-up (Long-term follow up with the primary treating surgeon)

 P  - Procedure (choice of the different operations)

 T - Technical (Specific variations of a particular procedure, i.e., size of the pouch in RNY, the length of the common channel in DS, or bougie size in DS)

 S - Supplements (Vitamin and mineral supplements needed)

SIPS-SADI

The SIPS-SADI procedure of the present is the simpler version of the Duodenal Switch for patients that have been gaining weight with the Sleeve, and other procedures.

There is no long-term data for SIPS-SADI procedure. The patient should be very clear in recognizing that SIPS-SADI is not the Duodenal Switch operation. Any presentation to that effect is inaccurate.

 A - Activity (An integral part of any healthy lifestyle, increase metabolic rate and building muscle mass)

 C - Complication (Complication of any surgical or medical treatment, i.e., hypertension with diet pills, leak with a surgical procedure)

 D - Diet (Healthy lifelong food selection are critical to lifelong weight management)

 E  - Expectation (What patients THINK the outcome a treatment is, may significantly differ from results documented by scientific data)

 F - Follow-up (Long-term follow up with the primary treating surgeon)

 P  - Procedure (choice of the different operations)

 T - Technical (Specific variations of a particular procedure, i.e., size of the pouch in RNY, the length of the common channel in DS, or bougie size in DS)

 S - Supplements (Vitamin and mineral supplements needed)

Gastric Balloon

Gastric Balloon is a clear example of over-promising and under-delivering.

It requires an endoscopy to place the Balloon(s) and removed them in six months. To maintain the minimal weight loss, patients need to have them replaced every six months (as of the publication date, not covered by any insurance) If the Balloon is removed and replaced, the patient may be able to maintain a 10% weight loss. Buyer beware.

 A - Activity (An integral part of any healthy lifestyle, increase metabolic rate and building muscle mass)

 C - Complication (Complication of any surgical or medical treatment, i.e., hypertension with diet pills, leak with a surgical procedure)

 D - Diet (Healthy lifelong food selection are critical to lifelong weight management)

 E  - Expectation (What patients THINK the outcome a treatment is, may significantly differ from results documented by scientific data)

 F - Follow-up (Long-term follow up with the primary treating surgeon)

 P  - Procedure (choice of the different operations)

 T - Technical (Specific variations of a particular procedure, i.e., size of the pouch in RNY, the length of the common channel in DS, or bougie size in DS)

 S - Supplements (Vitamin and mineral supplements needed)

ABOUT THE AUTHOR Dr. Ara Keshishian is Director and Surgeon at Central Valley Bariatrics. He has performed more than 2,000 Duodenal Switch procedures and 500+ revisions from other procedures such as RNY, Lap-Band & VSG to the DS since 1999. He has published several research articles on weight loss surgery topics. Read more articles from Dr. Keshishian!

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