Postoperative Resting Metabolic Rate and Successful Weight Loss After Roux-en-Y Gastric Bypass

Role of Endoluminal Functional Lumen Imaging Probe in Bariatric Surgery and Bariatric Endoscopy

Obesity is associated with significant morbidity, with an estimated prevalence of 42.4% in the USA. Treatment of severe obesity often involves Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy. More recently, endoscopic sleeve gastroplasty has emerged as a minimally invasive option for patients with mild to moderate obesity. Endoluminal functional luminal impedance planimetry (EndoFLIP) uses impedance planimetry to assess tissue distensibility and geometric changes across an area but its role in bariatric surgery and bariatric endoscopy has not been fully elucidated. EndoFLIP has some utility in measuring gastric sleeve pouch size during sleeve surgery, assessing gastric sleeve stenosis, predicting the risk of post-sleeve GERD and response to endoscopic dilation, assisting in intraoperative gastric bands adjustment, and evaluating gastrojejunal anastomosis to predict weight regain after gastric bypass.

Post metabolic bariatric surgery weight regain: the importance of GLP-1 levels

Weight regain and insufficient weight loss are essential problems after metabolic bariatric surgery (MBS) in people living with obesity. Changes in the level of glucagon-like peptide-1 (GLP-1) secreted from the gut after bariatric surgery are one of the underlying mechanisms for successful initial weight loss. Studies and meta-analyses have revealed that postprandial GLP-1 levels increase after the Roux-en-Y gastric bypass and sleeve gastrectomy, but fasting GLP-1 levels do not increase significantly. Some observational studies have shown the relationship between higher postprandial GLP-1 levels and successful weight loss after bariatric surgery. There is growing evidence that GLP-1-receptor agonist (GLP-1-RA) use in patients who regained weight after bariatric surgery has resulted in significant weight loss. In this review, we aimed to summarize the changes in endogenous GLP-1 levels and their association with weight loss after MBS, describe the effects of GLP-1-RA use on weight loss after MBS, and emphasize metabolic adaptations in light of the recent literature. We hypothesized that maintaining higher basal-bolus GLP-1-RA levels may be a promising treatment choice in people with obesity who failed to lose weight after bariatric surgery.

How to address weight regain after bariatric surgery in an individualized way

Bariatric surgery is the most effective obesity treatment. As a chronic and progressive disease, weight loss response to surgery will vary individually. Thus, insufficient weight loss or regain can happen after surgery, but they lack a standard definition. There are different mechanisms underlying weight regain and/or insufficient weight loss, such as genetics, maladaptive eating behaviors, and the inadequate choice of index operations, among others. Patients with weight regain or insufficient weight loss should be submitted to an individualized and comprehensive evaluation by a multidisciplinary team. This may help identify the causes and direct the appropriate treatment individually. Options for patients with insufficient weight loss and/or weight regain following bariatric surgery include repair of postoperative complications, conversion into another operation, endoscopic therapies with inconsistent outcomes, and dietary/behavioral counseling. Revision and conversion surgeries have higher complication rates than primary operations. Although there is no standard pharmacological regimen for that indication, the new agents seem efficient and safe to promote the loss of the regained weight and even be adjunctive to selected patients before they reach the plateau. This review aims to summarize the knowledge of the best approach for patients with weight regain/insufficient weight loss and suggests an algorithm to customize the approach and therapeutic options after bariatric surgery.