“ The long term results of RYGB are good and show significant health improvement and sustained weight loss. Nonetheless, a subset of patients either do not achieve sufficient weight loss or regain weight over time, with percentages varying from 4,2 – 7% of patients still having a BMI > 35kg/m² after 5 years of follow up to 10 – 40% of patients with <50% EWL after 5-7 years.
The exact reason for this failure has not been defined, but very likely, both life-style and technical factors contribute.
The main technical causes for weight regain after RYGB are suggested loss of restriction due to the enlargement of the gastric pouch, dilation of the gastrojejunostomy, and enlargement of the jejunum directly after the gastrojejunostomy. ”
Schauer et al.  refined this conclusion by examining the diameters of the pouch and the pouch outlet of former RYGB patients who experienced weight regain. Their findings were that especially the dilation of the GJ anastomosis contributed to the weight regain (see fig. 1) and that resolving the loss of restrictions by placing e.g. a gastric ring was a very effective counter measure.
Normal pouch, large stoma (n=86) Large pouch, normal stoma (n=42) (p=0.238) Large pouch, large stoma (n=18) (p<0.001)
Mean weight regain from lowest point postop (lb)
Fig. 1: Weight regain (pounds) after RYGB according to pouch and stoma dimensions. Enlargement of the gastrojejunostomy (GJ) stoma was associated with the greatest weight regain
When conservative treatment with nutritional counseling and psychological support has failed, several surgical options are available.
Conversions of the RYGB-construction to a longer alimentary limb for instance could theoretically lead to further weight loss, but could easily also result in serious malnutrition due to the shortening of the common limb. In addition, prospective studies comparing various alimentary limb lengths do not show increased weight loss in long-limb procedures.
Biliary Pancreatic Diversion and Duodenal Switch are effective alternatives, albeit both with severe undesirable side effects.
Banding the pouch is a relatively simple and straightforward measure to provide renewed restriction to the patient.
Dr. Valk  reported on a group of 74 patients who had regained weight a while after having had their initial bypass and found that placing a ring around the gastric pouch, when necessary partially resected, can result in >50% EWL in at least 75% of the patients within 1 year after placement of the ring. This translates into a further loss of on average 5 BMI points in the first 12 months. Partial pouch resection took place in about 25% of the cases.
Bessler  described a small prospective series of 22 patients who had regained weight or failed to reach >50% EWL, 18 months after their initial RYGB. Their pouches were banded leading to 59% EWL within 2 years, remaining stable up to the fifth and final year of the study (see fig. 1).
Fig. 2: Comparison of percentage of EWL between revision and combined procedures during 60 months of follow-up.
The timing of the revision procedure appears to be a critical factor in achieving renewed weight loss as well.
Schauer  pointed out that the positive contribution of banding the pouch in a revision procedure is stronger when the revision takes place within 5 years after the weight regain has set in. (see fig. 3). The longer one waits with banding the pouch, the less likely it will become to achieve >50% EWL.
< 5 years 5-10 years (p=0.561) > 10 years (p=0.670)
Mean % RWL post-revision procedure
Fig. 3: Box plot illustrating the percentage of regained weight lost by patients who underwent revision procedures to reduce size of their gastric pouch, stoma, or both according to their time of their presentation with significant weight gain after gastric bypass. Patients did not differ significantly in the percentage of regained weight lost (%RWL) based on whether they presented for a further weight loss intervention within 5 years, in 5 to 10 years, or as late as 10 years after Roux-en-Y gastric bypass (RYGB)
The recommended sizes of the gastric rings for revision of failed gastric bypasses are with 7.5cm – 8.0cm invariably larger than in primary banded gastric bypass (6,5cm).
Placing a gastric ring and, when required, resection of the gastric pouch after a failed RYGB is an effective approach which leaves other, more aggressive approaches like BPD and DS open for the future.
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