Open access peer-reviewed chapter

Weight Regain and Insufficient Weight Loss after Bariatric Surgery: A Call for Action

Written By

Wahiba Elhag and Walid El Ansari

Submitted: 21 July 2020 Reviewed: 30 October 2020 Published: 23 December 2020

DOI: 10.5772/intechopen.94848

From the Edited Volume

Bariatric Surgery - From the Non-Surgical Approach to the Post-Surgery Individual Care

Edited by Nieves Saiz-Sapena and Juan Miguel Oviedo

Chapter metrics overview

726 Chapter Downloads

View Full Metrics


Despite successful weight loss after bariatric surgery (BS), weight regain (WR) may occur on long term following most bariatric procedures, with 20–30% of patients either failing to reach their target weight goals or failing to maintain the achieved weight loss. Significant WR has important health consequences, including the reversal of the improved obesity-related comorbidities and psychological function leading to decreased quality of life. Given the challenges faced by these patients, there is a need for multidisciplinary approaches to deal with WR. This chapter addresses the issue of WR among bariatric patients. It starts with the various definitions of insufficient weight loss and WR and the prevalence of weight regain by type of bariatric procedure. The chapter then explores the underlying causes as well as the predictors of WR. It will also outline the behavioral and psychotherapeutic, dietary and exercise strategies employed in the prevention of post-surgery WR. The chapter will then highlight the non-surgical and surgical approaches used in the management of WR. The chapter will conclude with a summary of the findings emphasizing that WR is complex and multifactorial, requiring multidisciplinary and multimodal dietary, behavioral, pharmacological, and surgical management strategies tailored to meet the individual needs of each patient.


  • bariatric surgery
  • weight regain
  • insufficient weight loss
  • causes
  • predictors
  • management

1. Introduction

Bariatric surgery (BS) can achieve weight loss (WL), treat obesity-related metabolic disease and enhance the metabolic status by improving hypertension, type 2 diabetes mellitus (T2DM) and lipid profile, thereby decreasing the cardiovascular risk [1, 2]. Despite effective WL after BS, some patients do not achieve their target weight goals, and others regain a significant portion of their weight at long-term follow-up. Weight regain (WR) has a range of undesirable medical and psychological impacts [3, 4].

WR might occur after common BS procedures e.g. gastric bypass, adjustable gastric banding (LAGB), and sleeve gastrectomy (LSG), to different extents and at variable interval times [5]. The causes for WR are multifactorial, including patient- and procedure-specific factors [6, 7]. Interestingly, WR might occur despite the patients’ stated adherence to advised behavioral measures and absence of surgical anatomic causes. This suggests that various pre or post-operative demographic, physiologic or metabolic features could play a role. Given the complexity of the factors involved in WR, multimodal management strategies tailored to meet the individual needs of patients are essential.


2. Definitions of insufficient weight loss and weight regain

There is a distinction between two types of WL failure post BS: insufficient WL (IWL); and WR. The grouping of these two categories together should be discouraged. IWL is defined as excess weight loss (EWL%) of <50% at 18 months after BS [8], while WR is defined as regain of weight that occurs after achievement of an initial successful weight loss (defined as EWL% > 50%).

A range of definitions describe WR post BS [9, 10]. The lack of standard definition, consensus statements and guidelines leads to poor reporting and understanding of the significance of WR [3, 8, 10]. Moreover, clearer definitions will help to recognize when intervention is required and guide the intervention [8]. Available definitions include: regaining weight reaching a body mass index (BMI) >35 after successful WL [11]; an increase in BMI of ≥5 kg/m2 above the nadir weight [12]; > 25% EWL% regain from nadir [13, 14]; increase in weight of >10 kg from nadir [15, 16]; any WR [17]; any WR after type 2 diabetes mellitus (T2DM) remission [18]; or an increase of >15% of total body weight from nadir [19, 20]. The most common definition, an increase of ≥10 kg of nadir weight [15, 21], does little to define the clinical significance of the amount of WR in the affected individual. Therefore, a WR definition needs to be meaningful rather than arbitrary. It is important to note that multiple definitions affect the reporting of the prevalence of WR, and considerably change the reported outcomes. For instance, applying 6 different WR definitions to 55 patients 5 years after LSG led to WR rates ranging from 9–91% [10]. Similarly, the use of 5 continuous and 8 dichotomous measures among 1406 Roux en Y gastric bypass (RYGB) patients followed up for 5 years resulted in WR rates ranging from 44–87% [9]; and others reported rates between 16–37% WR 5 years post LAGB, LSG, and RYGB [19]. Therefore, more research is needed to define WR after BS in order to standardize its measurement.


3. Prevalence of WR and IWL after bariatric procedures

WR following BS varies by the type of BS performed, whether restrictive or malabsorptive as outlined below.

3.1 Laparoscopic gastric band (LAGB)

A large prospective multicenter study in Sweden found that 10 years post LAGB, patients regained 38% of the maximal weight they lost post surgery [1]. Likewise, research at 10 US hospitals that assessed weight trajectories among 2348 participants including 610 LAGB patients reported 1.4% WR 3 to 7 years after surgery [22] (Table 1).

Type of BSPrevalence of WR
LAGB1.4% between years 3 and 7 years [22]
38% at 10 years [1]
LSG5.7% at 2 years [3]
39.5% at 5 years [23]
76% over variable follow-up periods ranging from 2 to 6 years [3]
RYGB17.1% at 2 years [24]
22.5% at 3 years [9]
14.6%–26.8% at 5 years [9, 25]
3.9% between 3 and 7 years [22]

Table 1.

Prevalence of WR by type of BS.

LAGB: Laparoscopic gastric band; LSG: Laparoscopic sleeve gastrectomy; RYGB: Roux en Y gastric bypass.

3.2 Laparoscopic sleeve gastrectomy (LSG)

A systematic review of 21 studies reported WR rates post LSG ranging from 5.7% at 2 years to 76% over variable follow-up periods from (2 to 6 years) [3]. Other studies found that WR started three years after LSG [23]. At 5 years, WR (>10 kg) was observed in 39.5% of patients, where the EWL% decreased from 84.8% at one year to 57.3% after 5 years [23].

3.3 Roux en Y gastric bypass (RYGB)

Research among 1426 patients found that at 2 years, 17.1% regained >15% of their 1-year post-operative weight [24]. Others reported a 22.5% WR at 3 years and 26.8% at 5 years [9]. The Longitudinal Assessment of Bariatric Surgery (LABS) study observed 3.9% WR between 3 and 7 years post RYGB [22]. Others found that among 2965 patients, WR was 14.6% at 5 years post-surgery [25].


4. Causes of WR

Causes of WR following BS are multifactorial, and can be categorized into patient- and surgical-specific causes. The former includes hormonal causes and maladaptive lifestyle behaviors (e.g. dietary non-compliance and physical inactivity) [3, 7]. Other factors include the lack of follow-up support and mental health causes such as psychiatric conditions and maladaptive eating [3, 7]. Surgical-specific factors include e.g., enlargement of the gastric pouch or gastro-gastric fistula. Recognizing such underling etiologies is key to develop appropriate management strategies [26]. Figure 1 depicts the causes of WR.

Figure 1.

Summary of the causes, predictors and prevention and management strategies of weight regain.

4.1 Hormonal

Weight reduction following BS may be dependent to some extent on the ‘normalization’ of hormonal inputs. Furthermore, patients who fail to achieve WL post-BS or experience WR may have persistent hormonal ‘imbalances’ (e.g. high ghrelin, low peptide YY) which need to be addressed in order to accomplish WL.

Ghrelin is a hormone that is important in regulating food intake and energy balance. BS has a positive effect on ghrelin, where a significant decrease in both fasting and post prandial ghrelin is observed early after BS leading to decreased appetite and food intake [27]. However, research have found that among RYGB patients, subjects with WR had significantly higher pre and postoperative ghrelin levels compared to those who maintained or lost weight (722 ± 29 vs. 540 ± 156 pg/ml) [28]. Similarly, patients with WR 5 years post LSG had higher plasma ghrelin levels than their level at 1 year post surgery [16].

Peptide YY (PYY) is a 36 amino acid hormone that is released by the L-cells of the gastrointestinal tract after food intake to suppress appetite. Likewise, Glucagon-like protein-1 (GLP-1) is released after meals by L cells in the small intestine to stimulate insulin secretion, inhibit glucagon release, and delay gastric emptying [29]. Both these anorexigenic hormones display enhanced nutrient-stimulated secretion after BS, more so after RYGB than LSG [29]. However, the level of theses hormones was noticed to be lower in patients with WR. For instance, meal-stimulated gastric inhibitory polypeptide and glucagon-like peptide-1 (GLP-1) levels at 30 min were lower in 10 patients who had WR compared with 14 patients who successfully maintained WL post RYGB [30]. Whilst hormonal adaptation as a biological response to non-surgical WL has been examined [31], its influence on WR post BS is less documented in humans. For example, rodent studies showed that postsurgical WR was associated with failure to maintain elevated plasma PYY concentrations [32].

4.2 Nutritional non-adherence

Immediately following BS, caloric intake is reduced due to a smaller gastric capacity, diminished hunger, and increased satiety brought about by the anatomical and metabolic changes. Nevertheless, for some patients, caloric intake gradually increases over time which contributes to postoperative WR. In the Swedish Obesity Study, mean daily intakes of 2900, 1500, 1700,1800, 1900, and 2000 kcal/day were observed at baseline, 6 months, 12 months, 2 years, 3 years, and 4–10 years postsurgery respectively [1]. Such increase in food intake often begins in the second post-operative year, likely causing WR [1]. In addition, dietary non-adherence and the consumption of high-calorie foods and beverages contribute to the higher caloric intake leading to WR. A postoperative behavioral survey of 203 patients observed positive correlations between the magnitude of WR and evening or night consumption of large quantities of food, eating large amounts of high-fat foods, and eating out more frequently [33]. Equally, among 289 RYGB patients, 23% demonstrated dietary non-adherence and a continuation of pre-surgical eating patterns, leading to suboptimal weight loss and WR [34]. Such evidence substantiate the importance of diet quality and caloric intake as causative factors for WR after BS, and also highlight the importance of measuring and documenting the diet quality after BS [35].

Grazing behavior is the repeated episodes of consumption of smaller quantities of food over a long period of time accompanied by feelings of loss of control [36]. Those engaging in grazing nibbled continuously ≥2 days per week for a 6-month period, with an inability to stop or control their eating while nibbling [36]. Grazing contributes to poor weight outcomes post BS [37]. Although grazing and binge eating are similar as they involve subjective episodes of food consumption accompanied by a loss of control; however, grazing is physiologically more possible post BS than large binges. In 80% of patients with preoperative binge eating or grazing with loss of control, these behaviors returned 6 months post-surgery [36]. This suggests that preoperative binge eating may reemerge as postsurgical grazing in the context of a reduced stomach capacity [36].

Food indiscretion also contributed to WR. For instance, the follow up of 100 patients for 85 months after surgery revealed that poor dietary habits including consumption of excessive calories, snacks, sweets oils and fatty foods were statistically higher in WR patients [6]. This highlightes the importance of appropriate nutritional counselling for long-term weight maintenance. Lack of appropriate nutritional follow-up was also significantly associated with WR post BS [6]. For example, studies have found that among those with WR post-RYGB, 60% never maintained follow-up with appropriate nutritional consultants [38].

4.3 Physical Inactivity

Inadequate physical activity contributes to WR. Only 10–24% of BS patients met the guidelines regarding minimal physical activity for health promotion (i.e., ≥150 min/week or moderate-to-vigorous physical activity in bouts of ≥10 min) [39]. A meta-analysis of 14 studies and a literature review of 19 studies concluded that post-BS physical activity was significantly associated with greater WL [40]. Amongst 100 obese patients post-RYGB, those who performed physical activity had the lowest incidence of WR compared to those who were relatively inactive [6]. Barriers to exercise among bariatric patients such as health concerns, lack of proximity to a gym/park, or feeling self-conscious should be identified and addressed [40]. Such findings highlight the importance of measuring and documenting physical activity levels after BS [35].

Similarly, sedentary behavior, defined as ‘any waking behavior performed while in a sitting or reclining posture that requires very low energy expenditure’. The represents a risk factor for WR Sedentary behavior is associated with increased risk of obesity and related comorbidities [40]. Research have found that severely obese BS candidates are at high risk for SB [41]. In this study they found that BS candidates spent about 30% of their sedentary time watching television, suggesting that this is an important cause of sedentary behavior and should be a target for patient counseling [41].

4.4 Mental health

Mental health status prior to surgery is linked to WL following BS. Therefore, pre-operative psychological evaluation is important. Psychological factors might interfere with successful WL by undermining motivation, diet and exercise compliance, and other health behaviors critical to maintaining WL [42]. Among 60 adults who underwent RYGB or LAGB, 40% and 33.4% had single or multiple psychiatric diagnoses respectively, 47.5% stopped losing weight after 1 year, and 29.5% regained weight [43]. Furthermore, patients with ≥2 psychiatric conditions were 6 times more likely to either stop losing weight or regain weight relative to those with no or single psychiatric diagnosis [43]. Evidence supports the association between post-operative depressive disorders and poorer WL; however, the directionality of the relationship remains unknown [44]. More research is required to assess the long-term associations and directionality of depression and weight loss post BS.

4.5 Maladaptive eating: Binge eating (BE) disorder

Maladaptive eating patterns after BS have impact on weight and psychological outcomes [45]. One of these abnormal eating patterns is BE disorder which is defined as ‘the consumption of large quantities of food during a short amount of time without being in control of this behavior’, and is strongly associated with psychological distress [26]. BE disorder predicts poorer weight outcomes post BS, resulting in smaller BMI reductions as well as more WR [46, 47]. Despite the physical limitations of BS on stomach capacity, BE is not always abolished and many of those who had BE before BS still had feelings of loss of control when eating even small amounts of food post BS [37, 47]. Following RYGB, patients who regained >10% of their EWL% had significantly higher frequencies of BE and loss of control [46], and these maladaptive eating behaviors were significantly correlated with greater WR [46]. Follow up of 96 patients post RYGB two to seven years after surgery showed that binge eaters increased their BMI by 5.3 kg/m2 compared with 2.4 kg/m2 increase in non-binge eaters [48]. Likewise, among LAGB patients, the prevalence of eating disorder increased from 26.3% to 38.0% over one year post surgery, an increase that correlated with poorer WL outcomes [37].

4.6 Anatomic surgical failure

Each type of BS has its own potential mechanism/s of surgical failure that can lead to WR as outlined below.

4.6.1 Laparoscopic gastric band

LAGB success is correlated with appropriate follow-up, as saline adjustment of the band is essential for proper restriction and WL. Therefore, it is important to assess patients with WR after LAGB for potential pouch distension. Pouch distension is managed conservatively by complete band deflation, low calorie diet, reinforcement of portion size, and follow-up contrast study in 4–6 weeks, with success in more than 70% of patients [49]. On the other hand, premature removal of LAGB also causes WR. Studies have found that only 12% of patients with early band removal maintained their current weight [50]. Long term, LAGB removal rate is high, reaching 12% [51]. Moreover, after 14 years, the reoperation rate was as high as 30.5% with an average reoperation rate of 2.2% for every year of follow-up [51]. The main reason for LAGB removal was intolerance secondary to increased reflux type symptoms [52].

4.6.2 Laparoscopic sleeve gastrectomy

There are surgical causes of WR post LSG. The gastric sleeve may dilate over time leading to reduced restrictive effect and increase in gastric capacity, both associated with reduced satiety response and increased food intake resulting in WR [23]. For instance, among the 15.7% patients who had WR, CT scan volumetry showed that the mean gastric volume increased from 120 mL early after surgery to a mean of 240 mL at 3 years and to 524 mL at 5 years follow-up [23]. Several theories have been proposed as to the relationship of increased gastric volume and WR. One theory is that the physiologic dilation of the remnant stomach over time and the size of the gastric sleeve are linearly correlated with post-operative BMI [53, 54]. Another theory is the incomplete removal of the gastric fundus [55, 56], where in many cases, the dissection over the fundus, especially on the posterior aspect, may be difficult and technically demanding, notably in patients with the extreme obesity. Therefore, the success of LSG depends on the surgeon’s learning curve [55].

4.6.3 Roux-en-Y gastric bypass

RYGB produces WL through restriction of intake and malabsorption. In assessing WR post-RYGB, anatomical abnormalities are proposed to play a role. Dilatation of the gastric pouch or gastrojejunostomy (GJ) stoma outlet have been associated with loss of satiety with subsequent increase in food intake and WR [57, 58]. Among 205 RYGB patients who had upper endoscopy as workup for WR, dilation of the GJ was identified in 58.9%, enlarged gastric pouch in 28.8%, and both abnormalities in 12.3% of patients [57]. Multivariate analysis found that stoma diameter (>2 cm) was independently associated with WR [58], where among 28 patients following RYGB, WR was associated with dilated gastric stoma [59]. In this group, successful reduction in anastomotic size (<12 mm) with a sclerotic agent resulted in a mean 26-kg WL at 18 months [59].

Another anatomic change that reduces RYGB’S effectiveness is gastro-gastric fistula, an abnormal communication between the gastric pouch and the excluded stomach. This is thought to develop as a result of the breakdown of the surgical staple line. Although gastro-gastric fistulas are uncommon, with a 1.5–6% incidence rate [60]. Gastro-gastric fistulas have potentially significant effects as a complication after RYGB [60] as they may diminish the restrictive and malabsorptive components of RYGB leading WR [61].


5. Predictors of WR post BS

Knowledge of the preoperative predictors of WR post-BS can assist in identifying patients at risk for WR. The bariatric team can then offer such patients appropriate resources and counseling. Figure 1 depicts the predictors of WR.

5.1 Age

Age seems to be a predictor of WR, however, findings are inconsistent. Some smaller studies identified older age as a potential preoperative predictor of WR [62, 63]. Among 227 patients who underwent RYGB, older age (>60 years) predicted inadequate EWL% at 12 months [62]. While others found that younger individuals were more likely to have WR after RYGB [24].

5.2 Gender

Among post RYGB patients, male sex was associated with a worse weight trajectory [22] and suboptimal WL at 1 year after surgery [64]. Others found no effect of gender on weight loss outcomes [62].

5.3 Duration since surgery

Longer duration after BS predicted WR [24]. One study reported significant longer time since RYGB surgery in patients with WR (6 years) compared with patients who sustained their weight loss (3.3 years) [24]. Longer durations after surgery are probably associated with resolution of food intolerances, return to preoperative eating and other lifestyle patterns, anatomic surgical failure, or poor attendance of postoperative appointments [7, 65].

5.4 Preoperative BMI

Greater preoperative BMI was significantly associated with IWL [64]. A meta-analysis found that preoperative BMI and super-obesity were negatively associated with WL, where super-obese patients had 10.1 EWL% decrease [66]. Others observed that at 12 months post RYGB or LAGB, patients with baseline BMI ≥ 50 kg/m2 were more likely to have significant WR, but those with BMI < 50 kg/m2 were likely to continue losing weight [67]. Similarly, 80–100% of LSG patients with pre-surgery BMI > 40 kg/m2 had WR to BMI > 30 kg/m2 two years years after surgery; but only 3.6–38% of patients with lower pre-operative BMI (32.1–39.9 kg/m2) had BMI > 30 kg/m2 during the same time period [68].

5.5 Mental health

A presurgical BE disorder diagnosis predicted higher BMI. For example, studies found that among post-RYGB patients with 28.1 months mean follow-up, 79% reported WR and 15% regained ≥15% of their total weight loss [65]. The independent predictors of significant WR were lack of control of food urges (odds ratio, OR = 5.1), alcohol/drug use (OR = 12.74), lowest self-reported well-being scores (OR = 21.5), and lack of follow-up visits [65].

5.6 Presence of Comorbidities

Presence of T2DM predicts WR [22, 62, 63]. An assessment of 2348 bariatric participants in the Longitudinal Assessment of Bariatric Surgery (LABS) Study found that low HDL cholesterol and hypertension were also associated with an inferior weight trajectory [22].


6. Implications of weight regain

WR has important health consequences including recurrence of obesity related co-morbidities such as T2DM and deterioration in quality of life (QoL), thus contributing to socioeconomic and direct health care costs. This range of implications of WR is highlighted below.

6.1 Relapse of comorbidities

WR following BS is associated with and significantly predicted relapse of T2DM [12, 70]. At 10 year follow up, T2DM relapse was dependent on the extent of WR [70]. Patients with no WR had no relapse of their diabetes [70]. While, patients with mild regain (increase body weight > 5 kg from nadir) and severe regain (> 10 kg from nadir) had 5% and 17% relapse rates respectively [70]. Among 1406 RYGB patients with WR during the first year after reaching nadir weight, 25.8% and 46.2% of participants experienced progression of hyperlipidemia and hypertension respectively [9].

6.2 Quality of life

WR is significantly associated with deterioration in QoL [3, 9]. A study found that WR at 5 years after LSG was associated with a lower odds of satisfaction with surgery as measured by the Bariatric Analysis Reporting Outcome System (BAROS) score (incorporates weight loss, changes in medical conditions, health-related QoL, and reoperations) [3]. Others reported declines of physical and mental health–related QoL among 20.2% and 27.7% of patients with WR respectively [9]. Moreover, satisfaction with surgery also declined among 12.4% of patients with WR [9]. This decline was observed when the rate of WR was the highest, supporting a dose–response relationship (i.e., the less WR, the better) for physical health–related QoL [9].


7. Prevention of weight regain

Figure 1 summarizes the prevention strategies of WR. The foundation of prevention of WR after BS is aggressive behavioral interventions, similar to those utilized for medical weight management patients [33]. Behavioral modification components include commitment to regular structured physical activity, dietary control, nutritional optimization with substantive changes in eating practices and lifestyle habits [33, 71]. Other modulators include stress management, realistic goal setting, environmental control strategies, support systems, and cognitive restructuring [33, 71]. Close regular follow-up should start shortly after BS to reinforce nutritional and lifestyle instructions provided at discharge. Monitoring, education, and support should continue on the long term as the effectiveness of behavioral changes diminishes with time [33]. Self-monitoring with regular weight measurement, food records, and exercise diaries are essential tools for avoiding WR. These strategies increase patient’s awareness of eating patterns, and allow the bariatric dietitian to identify high-risk areas, such as nutritional inadequacy, food intolerances, poor food choices, or food dislikes that compromise weight loss and nutritional status [72]. In-person dietary counseling by a registered dietitian has an important role in prevention of WR post BS [73]. Structured physical activity is vital for weight prevention. An RCT demonstrated that a 5-month supervised exercise program post LSG resulted in reduction total body weight (TBW) and waist circumference with an increase in EWL% compared with the control group [74]. Conversely, stopping of the exercise program led to weight regain, with increased fat mass and decreased EWL% [74].


8. Management of WR

Figure 1 illustrates the management strategies of WR. WR after BS is complex and multifactorial [7]. Hence, management requires a holistic strategy addressing patient- and surgery-related factors that might contribute to WR. Dietary patterns, psychological disorders and physical activity levels should all be reviewed, as diet (25.3%), physical activity (21%) and motivational issues (19.7%) were the most common reasons among patients with WR [75]. Patients seeking BS often present with a range of mental health issues including mood, anxiety, addiction and personality disorders [7, 26]. Diagnosis and management of these conditions may improve outcomes following BS. As the patient undergoes psychological, dietary and physical activity counselling, it is critical to address the hormonal causes, and any anatomic/post-surgical changes that cause WR. Baseline anatomic studies include esophagogastroduodenoscopy or an upper gastrointestinal contrast to evaluate the GI tract [76]. These modalities provide essential data about the gastric remnant size, size of the gastrojejunal anastomosis, presence of gastro-gastric fistula, and location/integrity of the bands. Available treatment options include behavior interventions, WL-approved medications, endoscopic interventions and revision surgery to counter some of the factors that resulted in WR.

8.1 Behavioral

Psychological and behavioral factors that have negative impact on long term WL outcomes include life stressors that derail weight maintenance and decreased adherence to the recommended postoperative diet. This is likely due to lack of psychological skills to engage in long term healthy eating behaviors. This is particulalry important as the effects of surgery on appetite, hunger, and desire for food decrease. The aim is to address such challenges by behavioral therapy that is tailored to each patient’s need [77, 78]. Many patients with WR are lost to follow up; therefore, open, non-judgmental strategies that support the actions that patients are doing well are critical to motivate and involve patients in management [76].

A 6-week intervention of cognitive and dialectical behavior therapies among 29 RYGB patients (93% female) with WR of 37% of the initial WL, found that treatment completers had 1.6 ± 2.38 kg mean weight decrease compared with non completers [79]. Moreover, patients who completed behavior therapy treatment had improvement in their depressive symptoms with decreased grazing patterns (p ≤ 0.01), as well as subjective binge eating episodes (p ≤ 0.03) compared to non-completers [79]. Likewise, a 10-week behavioral intervention of psychological skills to mitigate WR among 11 patients after BS was feasible, acceptable (72% retention), and with high satisfaction among completers (4.25 out of 5.00)[80]. WR was stopped or reversed, with a mean 3.58 ± 3.02% total body WL% [80]. Similarly, the use of acceptance-based strategies and online or phone intervention delivery modes to enhance outcomes and reach more patients showed feasibility, acceptability (70% retention), efficacy, high satisfaction score of (4.7 out of 5.0), and reversal of WR with a mean 5.1 ± 5.5% total WL% at 3-month follow-up [81].

8.2 Dietary

Structured dietary interventions assist patients to improve WL. A randomized controlled trial (RCT) assigned post RYGB patients into two groups: a structured dietary intervention incorporating portion-controlled foods vs. a control group [77]. Both groups received behavioral WL instructions (one 60-min session followed by 4 coaching telephone calls at monthly intervals). The intervention group had significantly reduced calorie intake at 4 months (−108 vs. 116 Kcal) and increased WL% at 4 and 6 months compared to the control group (−4.56% vs. −0.13%, −4.07% vs. −0.14%, respectively) [77]. Another 16-week RCT among women who regained ≥5% of their lowest post-RYGB weight found that whey protein supplementation promoted WL and fat mass loss, with preserved muscle mass, compared to controls who gained weight (0.42 kg) and fat mass [82].

8.3 Pharmacological

Prior to 2012, the only FDA-approved WL drugs were orlistat, a modestly effective pancreatic lipase inhibitor with some side effects and phentermine, a sympathomimetic appetite suppressant approved for short-term use [83]. Since 2012, 4 other WL medications were approved [83]: phentermine-topiramate, bupropion hydrochloride-naltrexone hydrochloride, liraglutide and lorcaserin hydrochloride (withdrawn due to cancer risk [84]). Since then, anti-obesity medications have been increasingly used to manage WR post-BS. In an assessment of anti-obesity medications for WR/IWL among 319 patients (258 RYGB, 61 LSG), 54% lost ≥5% of their TBW, with many high responders (30.3% of patients lost ≥10%, and 15% lost ≥15% of their TBW) [85]. Of the 14 FDA approved and off-label anti-obesity medications, only topiramate showed statistically significant WL, where patients were 1.9 times more likely to lose ≥10% of their TBW [85]. Regardless of the postoperative BMI, RYGB patients were significantly more likely to lose ≥5% of their TBW with anti-obesity medications [85]. Another study of individual and combined anti-obesity medications for WR post RYGB reported that patients who received medications achieved significantly more WL compared to those not using anti-obesity medications [86]. Additionally, there was slower overall WR in the anti-obesity medications group during long term (11 year) follow up [86].

Among young adults post RYGB and LSG, topiramate, phentermine, and/or metformin led to 54.1%, 34.3% and 22.9% of patients losing ≥5% ≥10% and ≥ 15%, of their weight respectively [87]. Again, RYGB had higher median WL% than LSG (−8.1% vs. −3.3%), with no differences whether the anti-obesity medications were started at weight plateau or after WR [87]. In another study, phentermine was compered to phentermine–topiramate combination among RYGB or LAGB patients with WR and WL plateau [88]. The study showed that phentermine and phentermine–topiramate patients lost 6.35 kg (12.8% EWL%) and 3.81 kg (12.9% EWL%) respectively at 90 days post treatment [88].

Liraglutide, a GLP-1 analogue with central and peripheral actions, inhibits glucagon secretion, increases insulin secretion, decreases the gastric emptying rate, and promotes satiety [89]. In a recently published study, among 117 patients with WR after RYGB, LAGB and LSG, the use of liraglutide 3 mg over a 7 month period resulted in statistically significant WL (−6.3 ± 7.7 kg, P < .05) compared to baseline regardless of the type of surgery [90]. Moreover, the decrease in weight remained significant even after one year of liraglutide use [30]. In this study, nausea was the most prevalent side effect (29.1% patients) [90].

8.4 Surgical

Revision of a previous BS are carried out due to surgical complications e.g., development of intractable marginal ulcer, gastro-gastric fistula, severe gastroesophageal reflux, and malnutrition [91]. Recently, revisional surgery is increasingly utilized for the management of WR [91, 92].

8.4.1 After failed LAGB

In patients with WR or IWL after gastric band, the surgical options include band removal and revisional BS. A retrospective study evaluated the outcomes of revision of LAGB for inadequate weight loss to LSG or single anastomosis duodenal switch and found that patients who underwent single anastomosis duodenal switch had significantly greater weight loss than LSG in the first year post surgery, with excess BMI loss percentage of 66.7% versus 51.5% [93]. In the same study, at >12 months post revision, both single anastomosis duodenal switch patients and LSG patients had adequate WL (79% for single anastomosis duodenal switch versus 67.8% for LSG) [93]. A systematic review compared the WL outcomes of conversion gastric band to LSG or RYGB and showed significant increase in EWL% in RYGB and patients than LSG patients at 12 and 24 months after revision [94]. However, no statistically significant change was observed in terms of EWL% after 3, 6, or 36 months post revision [94]. RYGB was also associated with a higher rate of complications, readmission and longer operative time [94].

8.4.2 After failed LSG

Several surgical interventions can be considered for failed LSG including conversion to RYGB, biliopancreatic diversion with duodenal switch (BPD/DS), one anastomosis gastric bypass (OAGB) or single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). Among 43 post LSG patients who had revisional surgery for IWL/WR (25 patients converted to BPD/DS, 18 to RYGB), the median EWL% after 34 months was significantly greater for BPD/DS compared to RYGB (59% vs. 23%) [14]. However, short-term complications and vitamin deficiencies were higher in BPD/DS compared with RYGB [14].

Conversions of LSG to OAGB or RYGB are also utilized to manage WR. At 12 months, mean total WL percentage was significantly higher in OAGB compared to RYGB (15.8 ± 7.8% vs. 10.3 ± 7.6%), with no differences in readmission and complications between the two procedures, suggesting that OAGB is safe after failed LSG [95]. However, long-term follow up including the risk of malnutrition is needed for a complete evaluation of OAGB as a revisional BS. Another study evaluating the conversion of LSG to four different gastric bypass procedures including proximal RYGB, type 2 distal RYGB, long biliopancreatic limb RYGB and OAGB showed that the long biliopancreatic limb RYGB and OAGB resulted in significant EWL% at 3 years (33.8% and 33.2% respectively). However, the effect lasted only for 2 years in the proximal RYGB (EWL% of 23.1%) [96].

SADI-S is a relatively new procedure utilized as an alternative to the current duodenal switch (DS) [97]. Outcomes of SADI-S as a revision after LSG showed 20.5% weight loss and 9.4 units BMI change two years post revision with 93.7% T2DM remission rate [98]. Additionally, there were no mortality or conversions to open surgery, and postoperative early and late complication rates were low (5.3% and 6.4% respectively) [98].

8.4.3 After failed RYGB

There seems no standardized approach to revisional surgery after failed RYGB. A systemic review of revision of RYGB for WR (799 studies, 866 patients) assessed 5 revisions: conversion to distal RYGB or BPD/DS, or revision of gastric pouch and anastomosis, revision with gastric band or endoluminal procedures [92]. At 3-years after revision, mean excess body mass index loss percentage for distal RYGB was 52.2%, for BPD/DS was 76%, for gastric pouch or anastomosis revision was 14%, for gastric banding revision was 47.3%, and for endoluminal procedures was 32.1% [92]. Amongst these revisions, gastric pouch or anastomosis revision had the lowest rates for major complications (3.5%), while DRYGB had the highest rate for major complications (11.9%) and mortality (0.6%) [92]. A recently published study showed promising short and long term results as regards to the conversion of RYGB to long biliopancreatic limb RYGB for the management of IWL, where patients achieved an additional excess EWL% ranging from 40.0% at 1 year to 45.3% at 6 years [99].


9. Conclusions

Although BS is an effective treatment for weight loss and comorbidities resolution, however WR may occur on the long term. The lack of a standard definition and consensus on what constitutes clinically significance WR leads to poor reporting of this entity which requires further research. The underlying factors that contribute to WR are multifactorial, including hormonal and surgical causes, nutritional noncompliance, physical inactivity, and mental health issues. Therefore, patients with significant WR following BS should undergo comprehensive evaluations to determine the underlying etiology. Management should focus on preventive and treatment strategies delivered in a multidisciplinary approach to include dietary intervention, behavioral counseling, lifestyle modifications, pharmacotherapy and, if indicated, surgical revision. Future research should focus to identify the etiological factors and effective intervention strategies.



The publication fees of this chapter was funded by a grant from Novo Nordisk.

Conflict of interest



BMIbody mass index
BPD/DSlaparoscopic biliopancreatic diversion with duodenal switch
BSBariatric surgery
EWLexcess weight loss
FDAfood and drug administration
GLP-1polypeptide and glucagon-like peptide-1
IWLinsufficient weight loss
LAGBLaparoscopic gastric band
LSGLaparoscopic sleeve gastrectomy
OAGBone anastomosis gastric bypass
QoLquality of life
RCTrandomized controlled trial
RYGBRoux en Y gastric bypass
SADI-Ssingle anastomosis duodeno-ileal bypass with sleeve gastrectomy
T2DMtype 2 diabetes mellitus
TBWtotal body weight
WLweight loss
WRweight regain


  1. 1. Sjöström L, Lindroos A-K, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. The New England Journal of Medicine. 2004;351:2683-2693
  2. 2. Cho J-M, Kim HJ, Lo Menzo E, Park S, Szomstein S, Rosenthal RJ. Effect of sleeve gastrectomy on type 2 diabetes as an alternative treatment modality to Roux-en-Y gastric bypass: systemic review and meta-analysis. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11:1273-1280
  3. 3. Lauti M, Kularatna M, Hill AG, MacCormick AD. Weight Regain Following Sleeve Gastrectomy-a Systematic Review. Obesity Surgery. 2016;26:1326-1334
  4. 4. Noel P, Nedelcu M, Eddbali I, Manos T, Gagner M. What are the long-term results 8 years after sleeve gastrectomy? Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13:1110-1115
  5. 5. Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. Journal of Internal Medicine. 2013;273:219-234
  6. 6. Freire RH, Borges MC, Alvarez-Leite JI, Toulson Davisson Correia MI. Food quality, physical activity, and nutritional follow-up as determinant of weight regain after Roux-en-Y gastric bypass. Nutr Burbank Los Angel Cty Calif. 2012;28:53-58
  7. 7. Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obesity Surgery. 2013;23:1922-1933
  8. 8. Nedelcu M, Khwaja HA, Rogula TG. Weight regain after bariatric surgery-how should it be defined? Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12:1129-1130
  9. 9. King WC, Hinerman AS, Belle SH, Wahed AS, Courcoulas AP. Comparison of the Performance of Common Measures of Weight Regain After Bariatric Surgery for Association With Clinical Outcomes. Journal of the American Medical Association. 2018;320:1560-1569
  10. 10. Lauti M, Lemanu D, Zeng ISL, Su’a B, Hill AG, MacCormick AD. Definition determines weight regain outcomes after sleeve gastrectomy. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13:1123-1129
  11. 11. Carmeli I, Golomb I, Sadot E, Kashtan H, Keidar A. Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11:79-85
  12. 12. Brethauer SA, Aminian A, Romero-Talamás H, et al. Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Annals of Surgery. 2013;258:628-636 discussion 636-637
  13. 13. Liu SY-W, Wong SK-H, Lam CC-H, Yung MY, Kong AP-S, Ng EK-W. Long-term Results on Weight Loss and Diabetes Remission after Laparoscopic Sleeve Gastrectomy for A Morbidly Obese Chinese Population. Obesity Surgery. 2015;25:1901-1908
  14. 14. Homan J, Betzel B, Aarts EO, van Laarhoven KJHM, Janssen IMC, Berends FJ. Secondary surgery after sleeve gastrectomy: Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2015;11:771-777
  15. 15. Obeidat F, Shanti H, Mismar A, Albsoul N, Al-Qudah M. The Magnitude of Antral Resection in Laparoscopic Sleeve Gastrectomy and its Relationship to Excess Weight Loss. Obesity Surgery. 2015;25:1928-1932
  16. 16. Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, et al. Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin. Obesity Surgery. 2010;20:535-540
  17. 17. Jiménez A, Casamitjana R, Flores L, et al. Long-term effects of sleeve gastrectomy and Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus in morbidly obese subjects. Annals of Surgery. 2012;256:1023-1029
  18. 18. Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric Surgery Worldwide 2013. Obesity Surgery. 2015;25:1822-1832
  19. 19. Voorwinde V, Steenhuis IHM, Janssen IMC, Monpellier VM, van Stralen MM. Definitions of Long-Term Weight Regain and Their Associations with Clinical Outcomes. Obesity Surgery. 2020;30:527-536
  20. 20. Amundsen T, Strømmen M, Martins C. Suboptimal Weight Loss and Weight Regain after Gastric Bypass Surgery-Postoperative Status of Energy Intake, Eating Behavior, Physical Activity, and Psychometrics. Obesity Surgery. 2017;27:1316-1323
  21. 21. Abdallah E, El Nakeeb A, Youssef T, et al. Impact of extent of antral resection on surgical outcomes of sleeve gastrectomy for morbid obesity (a prospective randomized study). Obesity Surgery. 2014;24:1587-1594
  22. 22. Courcoulas AP, King WC, Belle SH, et al. Seven-Year Weight Trajectories and Health Outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study. JAMA Surgery. 2018;153:427-434
  23. 23. Braghetto I, Csendes A, Lanzarini E, Papapietro K, Cárcamo C, Molina JC. Is laparoscopic sleeve gastrectomy an acceptable primary bariatric procedure in obese patients? Early and 5-year postoperative results. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2012;22:479-486
  24. 24. Shantavasinkul PC, Omotosho P, Corsino L, Portenier D, Torquati A. Predictors of weight regain in patients who underwent Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12:1640-1645
  25. 25. Baig SJ, Priya P, Mahawar KK, Shah S. Indian Bariatric Surgery Outcome Reporting (IBSOR) Group. Weight Regain After Bariatric Surgery-A Multicentre Study of 9617 Patients from Indian Bariatric Surgery Outcome Reporting Group. Obesity Surgery. 2019;29:1583-1592
  26. 26. Kushner RF, Sorensen KW. Prevention of Weight Regain Following Bariatric Surgery. Current Obesity Reports. 2015;4:198-206
  27. 27. Sundbom M, Holdstock C, Engström BE, Karlsson FA. Early changes in ghrelin following Roux-en-Y gastric bypass: influence of vagal nerve functionality? Obesity Surgery. 2007;17:304-310
  28. 28. Tamboli RA, Breitman I, Marks-Shulman PA, et al. Early weight regain after gastric bypass does not affect insulin sensitivity but is associated with higher ghrelin levels. Obes Silver Spring Md. 2014;22:1617-1622
  29. 29. Yousseif A, Emmanuel J, Karra E, et al. Differential effects of laparoscopic sleeve gastrectomy and laparoscopic gastric bypass on appetite, circulating acyl-ghrelin, peptide YY3-36 and active GLP-1 levels in non-diabetic humans. Obesity Surgery. 2014;24:241-252
  30. 30. Santo MA, Riccioppo D, Pajecki D, et al. Weight Regain After Gastric Bypass: Influence of Gut Hormones. Obesity Surgery. 2016;26:919-925
  31. 31. Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. The New England Journal of Medicine. 2011;365:1597-1604
  32. 32. Meguid MM, Glade MJ, Middleton FA. Weight regain after Roux-en-Y: a significant 20% complication related to PYY. Nutr Burbank Los Angel Cty Calif. 2008;24:832-842
  33. 33. Zalesin KC, Franklin BA, Miller WM, et al. Preventing Weight Regain After Bariatric Surgery: An Overview of Lifestyle and Psychosocial Modulators. Am J Lifestyle Med. SAGE Publications. 2010;4:113-120
  34. 34. Rusch MD, Andris D. Maladaptive eating patterns after weight-loss surgery. Nutr Clin Pract Off Publ Am Soc Parenter Enter Nutr. 2007;22:41-49
  35. 35. El Ansari W, El-Ansari K. Missing Something? Comparisons of Effectiveness and Outcomes of Bariatric Surgery Procedures and Their Preferred Reporting: Refining the Evidence Base. Obesity Surgery. 2020;30:3167-3177
  36. 36. Saunders R. “Grazing”: a high-risk behavior. Obesity Surgery. 2004;14:98-102
  37. 37. Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obes Silver Spring Md. 2008;16:615-622
  38. 38. Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC. Long-term weight regain after gastric bypass: a 5-year prospective study. Obesity Surgery. 2008;18:648-651
  39. 39. Rosenberger PH, Henderson KE, White MA, Masheb RM, Grilo CM. Physical activity in gastric bypass patients: associations with weight loss and psychosocial functioning at 12-month follow-up. Obesity Surgery. 2011;21:1564-1569
  40. 40. Livhits M, Mercado C, Yermilov I, et al. Exercise following bariatric surgery: systematic review. Obesity Surgery. 2010;20:657-665
  41. 41. Bond DS, Thomas JG, Unick JL, Raynor HA, Vithiananthan S, Wing RR. Self-reported and objectively measured sedentary behavior in bariatric surgery candidates. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2013;9:123-128
  42. 42. Sarwer DB, Wadden TA, Moore RH, et al. Preoperative eating behavior, postoperative dietary adherence, and weight loss after gastric bypass surgery. Surgery for Obesity and Related Diseases. 2008;4:640-646
  43. 43. Rutledge T, Groesz LM, Savu M. Psychiatric factors and weight loss patterns following gastric bypass surgery in a veteran population. Obesity Surgery. 2011;21:29-35
  44. 44. Sheets CS, Peat CM, Berg KC, et al. Post-operative psychosocial predictors of outcome in bariatric surgery. Obesity Surgery. 2015;25:330-345
  45. 45. Mitchell JE, Christian NJ, Flum DR, et al. Postoperative Behavioral Variables and Weight Change 3 Years After Bariatric Surgery. JAMA Surgery. 2016;151:752-757
  46. 46. Kofman MD, Lent MR, Swencionis C. Maladaptive eating patterns, quality of life, and weight outcomes following gastric bypass: results of an Internet survey. Obes Silver Spring Md. 2010;18:1938-1943
  47. 47. Freire CC, Zanella MT, Segal A, Arasaki CH, Matos MIR, Carneiro G. Associations between binge eating, depressive symptoms and anxiety and weight regain after Roux-en-Y gastric bypass surgery. Eat Weight Disord EWD. 2020; Jan 2. doi: 10.1007/s40519-019-00839-w. Online ahead of print
  48. 48. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB. Binge eating among gastric bypass patients at long-term follow-up. Obesity Surgery. 2002;12:270-275
  49. 49. Eid I, Birch DW, Sharma AM, Sherman V, Karmali S. Complications associated with adjustable gastric banding for morbid obesity: a surgeon’s guides. Can J Surg J Can Chir. 2011;54:61-66
  50. 50. Lanthaler M, Strasser S, Aigner F, Margreiter R, Nehoda H. Weight loss and quality of life after gastric band removal or deflation. Obesity Surgery. 2009;19:1401-1408
  51. 51. Stroh C, Köckerling F, Volker L, et al. Results of More Than 11,800 Sleeve Gastrectomies: Data Analysis of the German Bariatric Surgery Registry. Annals of Surgery. 2016;263:949-955
  52. 52. Kuzmak null, Burak null. Pouch Enlargement: Myth or Reality? Impressions from Serial Upper Gastrointestinal Series in Silicone Gastric Banding Patients. Obes Surg. 1993;3:57-62
  53. 53. Weiner RA, Weiner S, Pomhoff I, Jacobi C, Makarewicz W, Weigand G. Laparoscopic sleeve gastrectomy--influence of sleeve size and resected gastric volume. Obesity Surgery. 2007;17:1297-1305
  54. 54. Braghetto I, Cortes C, Herquiñigo D, et al. Evaluation of the radiological gastric capacity and evolution of the BMI 2-3 years after sleeve gastrectomy. Obesity Surgery. 2009;19:1262-1269
  55. 55. Noel P, Nedelcu M, Nocca D, et al. Revised sleeve gastrectomy: another option for weight loss failure after sleeve gastrectomy. Surgical Endoscopy. 2014;28:1096-1102
  56. 56. Iannelli A, Schneck AS, Noel P, Ben Amor I, Krawczykowski D, Gugenheim J. Re-sleeve gastrectomy for failed laparoscopic sleeve gastrectomy: a feasibility study. Obesity Surgery. 2011;21:832-835
  57. 57. Yimcharoen P, Heneghan HM, Singh M, et al. Endoscopic findings and outcomes of revisional procedures for patients with weight recidivism after gastric bypass. Surgical Endoscopy. 2011;25:3345-3352
  58. 58. Heneghan HM, Yimcharoen P, Brethauer SA, Kroh M, Chand B. Influence of pouch and stoma size on weight loss after gastric bypass. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2012;8:408-415
  59. 59. Catalano MF, Rudic G, Anderson AJ, Chua TY. Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision. Gastrointestinal Endoscopy. 2007;66:240-245
  60. 60. Cucchi SG, Pories WJ, MacDonald KG, Morgan EJ. Gastrogastric fistulas. A complication of divided gastric bypass surgery. Annals of Surgery. 1995;221:387-391
  61. 61. Filho AJB, Kondo W, Nassif LS, Garcia MJ, Tirapelle R de A, Dotti CM. Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass. JSLS. 2006;10:326-31
  62. 62. Al-Khyatt W, Ryall R, Leeder P, Ahmed J, Awad S. Predictors of Inadequate Weight Loss After Laparoscopic Gastric Bypass for Morbid Obesity. Obesity Surgery. 2017;27:1446-1452
  63. 63. Paul L, van der Heiden C, Hoek HW. Cognitive behavioral therapy and predictors of weight loss in bariatric surgery patients. Current Opinion in Psychiatry. 2017;30:474-479
  64. 64. Melton GB, Steele KE, Schweitzer MA, Lidor AO, Magnuson TH. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2008;12:250-255
  65. 65. Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obesity Surgery. 2010;20:349-356
  66. 66. Livhits M, Mercado C, Yermilov I, et al. Preoperative predictors of weight loss following bariatric surgery: systematic review. Obesity Surgery. 2012;22:70-89
  67. 67. Ochner CN, Jochner MCE, Caruso EA, Teixeira J, Xavier P-SF. Effect of preoperative body mass index on weight loss after obesity surgery. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2013;9:423-427
  68. 68. Csendes A, Burgos AM, Martinez G, Figueroa M, Castillo J, Díaz JC. Loss and Regain of Weight After Laparoscopic Sleeve Gastrectomy According to Preoperative BMI : Late Results of a Prospective Study (78-138 months) with 93% of Follow-Up. Obesity Surgery. 2018;28:3424-3430
  69. 69. Marek RJ, Ben-Porath YS, Dulmen MHM van, Ashton K, Heinberg LJ. Using the presurgical psychological evaluation to predict 5-year weight loss outcomes in bariatric surgery patients. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13:514-521
  70. 70. Capoccia D, Guida A, Coccia F, et al. Weight Regain and Diabetes Evolution After Sleeve Gastrectomy: a Cohort Study with over 5 Years of Follow-Up. Obesity Surgery. 2020;30:1046-1051
  71. 71. Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obesity Surgery. 2004;14:1148-1156
  72. 72. McGrice M, Don PK. Interventions to improve long-term weight loss in patients following bariatric surgery: challenges and solutions. Diabetes Metab Syndr Obes Targets Ther. 2015;8:263-274
  73. 73. Swenson BR, Saalwachter Schulman A, Edwards MJ, Gross MP, Hedrick TL, Weltman AL, et al. The effect of a low-carbohydrate, high-protein diet on post laparoscopic gastric bypass weight loss: a prospective randomized trial. The Journal of Surgical Research. 2007;142:308-313
  74. 74. Marc-Hernández A, Ruiz-Tovar J, Aracil A, Guillén S, Moya-Ramón M. Effects of a High-Intensity Exercise Program on Weight Regain and Cardio-metabolic Profile after 3 Years of Bariatric Surgery: A Randomized Trial. Sci Rep [Internet]. 2020 [cited 2020 Aug 29];10. A
  75. 75. Thompson CC, Slattery J, Bundga ME, Lautz DB. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Surgical Endoscopy. 2006;20:1744-1748
  76. 76. Velapati SR, Shah M, Kuchkuntla AR, et al. Weight Regain After Bariatric Surgery: Prevalence, Etiology, and Treatment. Curr Nutr Rep. 2018;7:329-334
  77. 77. Kalarchian MA, Marcus MD, Courcoulas AP, Cheng Y, Levine MD, Josbeno D. Optimizing long-term weight control after bariatric surgery: a pilot study. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2012;8:710-715
  78. 78. Sarwer DB, Dilks RJ, West-Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2011;7:644-651
  79. 79. Himes SM, Grothe KB, Clark MM, Swain JM, Collazo-Clavell ML, Sarr MG. Stop regain: a pilot psychological intervention for bariatric patients experiencing weight regain. Obesity Surgery. 2015;25:922-927
  80. 80. Bradley LE, Forman EM, Kerrigan SG, Butryn ML, Herbert JD, Sarwer DB. A Pilot Study of an Acceptance-Based Behavioral Intervention for Weight Regain After Bariatric Surgery. Obesity Surgery. 2016;26:2433-2441
  81. 81. Bradley LE, Forman EM, Kerrigan SG, et al. Project HELP: a Remotely Delivered Behavioral Intervention for Weight Regain after Bariatric Surgery. Obesity Surgery. 2017;27:586-598
  82. 82. Lopes Gomes D, Moehlecke M, Lopes da Silva FB, Dutra ES, D’Agord Schaan B, Baiocchi de Carvalho KM. Whey Protein Supplementation Enhances Body Fat and Weight Loss in Women Long After Bariatric Surgery: a Randomized Controlled Trial. Obes Surg. 2017;27:424-31
  83. 83. Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. Oxford Academic. 2015;100:342-362
  84. 84. Tak YJ, Lee SY. Anti-Obesity Drugs: Long-Term Efficacy and Safety: An Updated Review. World J Mens Health. 2020; Mar 9. doi: 10.5534/wjmh.200010. Online ahead of print
  85. 85. Stanford FC, Alfaris N, Gomez G, et al. The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13:491-500
  86. 86. Istfan NW, Anderson WA, Hess DT, Yu L, Carmine B, Apovian CM. The Mitigating Effect of Phentermine and Topiramate on Weight Regain After Roux-en-Y Gastric Bypass Surgery. Obes Silver Spring Md. 2020;28:1023-1030
  87. 87. Toth AT, Gomez G, Shukla AP, et al. Weight Loss Medications in Young Adults after Bariatric Surgery for Weight Regain or Inadequate Weight Loss: A Multi-Center Study. Child Basel Switz. 2018;5
  88. 88. Schwartz J, Chaudhry UI, Suzo A, et al. Pharmacotherapy in Conjunction with a Diet and Exercise Program for the Treatment of Weight Recidivism or Weight Loss Plateau Post-bariatric Surgery: a Retrospective Review. Obesity Surgery. 2016;26:452-458
  89. 89. C Sudlow A, W le Roux C, J Pournaras D. Review of Advances in Anti-obesity Pharmacotherapy: Implications for a Multimodal Treatment Approach with Metabolic Surgery. Obesity Surgery 2019;29:4095-104
  90. 90. Wharton S, Kuk JL, Luszczynski M, Kamran E, Christensen RAG. Liraglutide 3.0 mg for the management of insufficient weight loss or excessive weight regain post-bariatric surgery. Clin Obes. 2019;9:e12323
  91. 91. Callahan ZM, Su B, Kuchta K, Linn J, Carbray J, Ujiki M. Five-year results of endoscopic gastrojejunostomy revision (transoral outlet reduction) for weight gain after gastric bypass. Surgical Endoscopy. 2020;34:2164-2171
  92. 92. Parmar CD, Gan J, Stier C, Dong Z, Chiappetta S, El-Kadre L, et al. One Anastomosis/Mini Gastric Bypass (OAGB-MGB) as revisional bariatric surgery after failed primary adjustable gastric band (LAGB) and sleeve gastrectomy (SG): A systematic review of 1075 patients. Int J Surg Lond Engl. 2020;81:32-38
  93. 93. Pearlstein S, Sabrudin SA, Shayesteh A, Tecce ER, Roslin M. Outcomes After Laparoscopic Conversion of Failed Adjustable Gastric Banding (LAGB) to Laparoscopic Sleeve Gastrectomy (LSG) or Single Anastomosis Duodenal Switch (SADS). Obesity Surgery. 2019;29:1726-1733
  94. 94. Wu C, Wang F-G, Yan W-M, Yan M, Song M-M. Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding. Obesity Surgery. 2019;29:3252-3263
  95. 95. Chiappetta S, Stier C, Scheffel O, Squillante S, Weiner RA. Mini/One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as a Second Step Procedure After Sleeve Gastrectomy-a Retrospective Cohort Study. Obesity Surgery. 2019;29:819-827
  96. 96. Kraljević M, Süsstrunk J, Köstler T, Lazaridis II, Zingg U, Delko T. Short or Long Biliopancreatic Limb Bypass as a Secondary Procedure After Failed Laparoscopic Sleeve Gastrectomy. Obes Surg. 2020; Jul 23. doi: 10.1007/s11695-020-04868-8. Online ahead of print
  97. 97. Brown WA, Ooi G, Higa K, Himpens J, Torres A, IFSO-appointed task force reviewing the literature on SADI-S/OADS. Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement. Obes Surg. 2018;28:1207-16
  98. 98. Zaveri H, Surve A, Cottam D, et al. A Multi-institutional Study on the Mid-Term Outcomes of Single Anastomosis Duodeno-Ileal Bypass as a Surgical Revision Option After Sleeve Gastrectomy. Obesity Surgery. 2019;29:3165-3173
  99. 99. Kraljević M, Köstler T, Süsstrunk J, Lazaridis II, Taheri A, Zingg U, et al. Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters. Obesity Surgery. 2020;30:804-811

Written By

Wahiba Elhag and Walid El Ansari

Submitted: 21 July 2020 Reviewed: 30 October 2020 Published: 23 December 2020