Management of Weight Regain Clinical Case Post Bariatric Surgery · 2019-08-16 · weight regain....

Management of Weight Regain

Clinical Case Post Bariatric Surgery

Case Study Teaching Workshop

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Anni

LSG

MOURNING

Age: 56 yearsBMI: 37,3 kg/m2

T2DM in metforminMild depression in the past

Long-standing obesityRegular eating at mealsSometimes snacking at home

The case of Rosella

Bariatric Surgery: Weight regain

Schauer PA. NEJM 2017;376:641

Peterli R. JAMA 2018;319:255

Bariatric Surgery: Weight Regain

Adams T et al. NEJM 2017;377:1143


Kofman MD et al. Obesity 2010;18:1938

497 RYGB patients: 81% MAX EWL → 70% EWL 3-10 yrs after surgery (mean 4.2 yrs)


Question 1. What you should perform FIRST for Rosella?

• Revisional Surgery

• Reinforcement of the lifestyle modifications programme

• Prescription of a weight-loss drug

• Evaluation of the functionality/anatomy of the first procedure


Question 1. What you should perform FIRST for Rosella?

A. Evaluation of the functionality/anatomy of the first procedure





II) Surgery-related: - Adjustable gastic banding: Pouch distensionBand removal

- Roux-en-Y bypass: Stoma dilatationPouch dilatationGastro-gastric fistulae

- Sleeve Gastrectomy: Sleeve dilatation

I) Patient-related: - Dietary non-compliance: Poor diet qualityInappropriate food choicesLack of nutritional counseling

- Mental health disorders: Binge eatingGrazing behaviours

- Physical inactivity

- Hormonal/metabolic: GhrelinGlucose homeostasis

Karmali et al. Obes Surg 2013;23:1922-33


EGDS: Normal for LSGRx Upper digestive tract: Normal for LSG

LABS data:

- Normal HbA1c- No micronutrients deficits

The case of Rosella

Question 2. What you should perform SECOND for Rosella?






Question 2. What you should perform SECOND for Rosella?


B. Reinforcement of the lifestyle modifications programme




Mitchell JE et al. JAMA Surg 2016;151:752


Rudolph A & Hilbert A. Obes Rev 2013;14:292


There was a positiverelationship between

increased exerciseand weight loss aftersurgery in 15 studies


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LIFESTYLE REINFORCEMENT

The case of Rosella

Question 3. What you should perform THIRD for Rosella?






Question 3. What you should perform THIRD for Rosella?



C. Prescription of a weight-loss drug



Question 3bis. Which drugs do you suggest for Rosella?

o Xenical

o Liraglutide 3.0 mg

o Fixed combination Naltrexone / Bupropion


Schwartz J et al. Obes Surg 2016;26:452


Stanford FM et al. SOARD 2017;13:491

The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study

MethodsWe completed a restrospective study to identify patients who had undergone bariatric surgery in the form of a Roux-en-Y gastric bypass (RYGB) or a sleeve gastrectomy from 2000–2014. From this cohort, we identified patients who were placed on weight loss pharmacotherapy postoperatively for inadequate weight loss or weight regain. We extracted key demographic data, medical history, and examined weight loss in response to surgery and after the initiation of weight loss pharmacotherapy.

ResultsA total of 319 patients (RYGB = 258; sleeve gastrectomy = 61) met inclusion criteria for analysis. More than half (54%; n = 172) of all study patients lost≥5% (7.2 to 195.2 lbs) of their total weight with medications after surgery. There were several high responders with 30.3% of patients (n = 96) and 15% (n = 49) losing≥10% (16.7 to 195.2 lbs) and≥15% (25 to 195.2 lbs) of their total weight, respectively.


Toth AT et al. Children 2018;5(9)


Rye P et al. Obes Surg 2018;28:3553


Hanipah ZN et al. SOARD 2018;14:93-98

209 pts

156 pts (74.6%)

25 pts (12.0%)

18 pts (8.6%)

10 pts (4.8%)


Hanipah ZN et al. SOARD 2018;14:93-98


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MOURNING

LIFESTYLE REINFORCEMEN

NALTREXONE/BUPROPIONE

The case of Rosella

Question 3. What you should perform FORTH for Rosella?






Question 3. What you should perform FORTH for Rosella?




D. Revisional Surgery


Bariatric Surghery: Weight regain

Angrisani L et al. Obes Surg 2018

WEIGHT REGAINPOST BS

RE-DO SURGERY


WEIGHT REGAINPOST BS

RE-DO SURGERY

- The risk of surgical complications is higherthan in primary procedures.

- We have no good quality data on weightloss in the long-term.

- Tendency to shift toward malabsorptiveprocedures with a higher risk of long-termnutritional complications.



The first consensus statement on revisional bariatric surgery using a modified Delphi approach.

BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS.METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus.RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%).CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Surg Endosc 2019 Jun 19. doi: 10.1007/s00464-019-06937-1. [Epub ahead of print]

What you should perform for Rosella?




D. Revisional Surgery


Thanks for yourattention !!!

[email protected]

Luca Busetto

@busetto_luca

Management of Weight Regain Clinical Case Post Bariatric Surgery · 2019-08-16 · weight regain....

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