Dealing with weight regain after Roux-en-Y gastric bypass

Dealing with weight regain after Roux-en-Y gastric bypass: surgical approach

Robin Blackstone, MD, FACS

Masters of Minimally Invasive Bariatric Surgery

April 5, 2013 Orlando, Florida

Disclosures

• PI Enteromedics VBLOC and Recharge Trials

• Consulting Johnson and Johnson/Ethicon Surgical

Changing Semantics

• Remission of weight

• Partial Remission of weight

• Weight regain

• ELIMINATE THE WORD FAILURE….

Weight Loss after RYGB is Widely

and Normally Distributed

10

0%

5 65 140

% Excess Body Weight Loss at 1 year

Nu

mb

er

of P

atie

nts

5

75

150

n=682

50

%

Hatoum IJ et al. Obesity 2009; 17(1):98-9.

Adams T. et al. JAMA September 19, 2012

Bariatric Surgery

Evidence for Physiological Mechanisms

1. Dramatic effects on hunger and satiety

2. Few patients become underweight after surgery

3. Transient weight gain during pregnancy

4. Little or no weight loss in thin patients or animals

5. Changes in GI endocrine markers – ghrelin, PYY, GLP-1, amylin

6. Increased energy expenditure (bypass procedures)

7. Ability to reverse effects of surgery with drugs and genetic

manipulation

Anatomic Dissection of RYGB

Gastric Bypass: Five Operations

5. Partial vagotomy


1. Isolation of gastric cardia


2. Exclusion of distal stomach


3. Exclusion of duodenum

and proximal jejunum

4

3

ELS

10 cm


4. Exposure of distal intestine

to undigested nutrients

Altering the “Set Point” with Gastric

Surgery

30 35 40 45

Body Mass Index (kg/m2)

kcal / 24

ho

urs

2000

2500

3000

Baseline

Energy

Expenditure

Baseline

Energy

Intake

Post-op

Energy

Intake

Post-op

Energy

Expenditure

RYGB: Resolution of the “Overfed”

State

30 35 40 45

Body Mass Index (kg/m2)

kcal / 24

ho

urs

2000

2500

3000 Post-op

Energy

Intake

Post-op

Energy

Expenditure

Overfed state

RYGB Mimics the Overfed State

0 25 50 75 100 125 150 175 200200

250

300

350Overfed

Control

Food Restricted

Days

Bo

dy W

eig

ht

(g)

Resolution of the overfed state

RYGB Mimics the Overfed State

0 25 50 75 100 125 150 175 200200

250

300

350Overfed

Control

Food Restricted

Days

Bo

dy W

eig

ht

(g)

Resolution of the overfed state

OLD model

of RYGB

CURRENT model

of RYGB

Set Point and Weight Regain F

at M

ass S

et P

oin

t

Time (years)

Aging and environmental influences (no intervention)

Surgery Environmental influences

and aging

RYGB Induces Weight Loss in Mice

40

60

80

100

120

0 1 2 3 4 5 6 7 8 9 10 11

Time after Surgery (Weeks)

% P

reo

pera

tive B

od

y W

eig

ht

Sham

RYGB

Stylopoulos N et al. Obesity 2009; 17(10):1839-1847.

0

2000

4000

6000

8000

10000

12000

14000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Time (Weeks)

RYGB

Sham

RYGB Reduces Nutrient Intake

Cu

mu

lati

ve F

oo

d I

nta

ke

(kcal)


RYGB Selectively Reduces Body Fat

0

10

20

30

40

50

60

Sham RYGB

Bo

dy C

om

po

sit

ion

(G

ram

s) Fat Mass

Lean Body Mass


Nutr

ient A

bsorp

tion

(%)

Before

RYGB

After

RYGB

Stool Calorimetry

RYGB Does Not Alter Caloric

Absorption


RYGB Increases Energy Expenditure

400

500

600

700

800

900

1000

1100

1200

400

450

500

550

600

650

700

750

800

850

900

TE

E -

VO

2 (

ml/hr/

kg

.75)

RE

E -

VO

2 (

ml/hr/

kg

.75)

Sham RYGB Weight-matched * p<0.05

** p<0.001

** ** *

** ** *


GI Endocrine Responses to RYGB

Time after start of meal (min)

0 20 40 60 80 100

Active G

LP

-1 (

pg/m

l)

0

50

100

150

200

250

300RYGB

Sham

Lean

5 min mixed meal

-10

*

#

*

**


0 20 40 60 80 100P

YY

(p

g/m

l)

0

50

100

150

200

250

300RYGB

Sham

Lean

5 min mixed meal

-10

*

**

**

**


0 20 40 60 80 100P

YY

(p

g/m

l)

0

50

100

150

200

250

300RYGB

Sham

Lean

5 min mixed meal

-10

*

**

**

**


0 20 40 60 80 100

GIP

(p

g/m

l)

0

100

200

300

400

500

600

5 min mixed meal

-10


0 20 40 60 80 100

Active

Am

ylin

(p

g/m

l)

0

50

100

150

200

250

5 min mixed meal

-10

*

*


0 20 40 60 80 100

Acyl

ate

d G

hre

lin (

pg

/ml)

0

50

100

150

200

250

300 RYGB

Sham

Lean

5 min mixed meal

-10

**

GLP-1 PYY Amylin

Ghrelin GIP

Shin AC et al. Endocrinology 2010; 151(4):1588-1597.

GLP-1 levels in human after RYGB

Peterli R et al. Ann Surg 2009; 250(2):234-41.

Endocrine Effects of GI Manipulations Ghrelin GLP-1 PYY GIP

Gastric

Banding

Sleeve

gastrectomy * *

Gastric

Bypass

Decreased

Initially * *

BPD/DS * * *

*Post-prandial

Clinical Predictors of RYGB Weight

Loss

• Increased preoperative BMI

• Presence of T2DM

– Duration of T2DM

– ? Relationship with b-cell failure

• Lack of physical activity

• Increased patient age

• Inadequate surgical “restriction”

– Pouch size

– Diameter of gastro-jejunal anastomosis

• Lack of patient follow-up / compliance

• None of these predictors is sufficiently

powerful to determine clinical practice

Associations with more modest weight loss

Carbohydrate eating leads to weight regain

• When a post GBP patient eats any simple sugar (carbohydrates: rice, pasta, bread, potatoes) then evoke a very strong GLP1 response

• The GLP1 drives the release of insulin which outlasts the simple sugar in the blood causing a relative low blood sugar which drives eating

• This occurs over and over all day with subsequent weight regain

Intensive Medical/Behavioral Therapy

• STOP eating any carbs except in green vegetables

• Need to increase energy expenditure and drive body fat percent below 30% in order to reengage the LEPTIN coupling with metabolism (good evidence for Leptin resistance at Body Fat >30%)

• Get the original set of parameters to work for the patient

So what is there to revise?

• Possible options:

– Revise the gastrojejunostomy

– Take out the distal remnant (decrease ghrelin)

– Lengthen the Roux limb

– Convert to Sleeve/ Duodenal switch

THANK YOU

Documents

Dealing with weight regain after Roux-en-Y gastric bypass