OBES SURG (2016) 26:2654–2660

DOI 10.1007/s11695-016-2165-5

ORIGINAL CONTRIBUTIONS

Early Weight Recidivism Following Laparoscopic Sleeve

Gastrectomy: A Prospective Observational Study
Mohamed H. A. Fahmy 1 & Mohamed D. Sarhan 1 & Ayman M. A. Osman 1 &
Ahmad Badran 1 & Amr Ayad 1 & Dalia K. Serour 2 & Hany A. Balamoun 1 &
Mohamed E. Salim 1

Published online: 7 April 2016

# Springer Science+Business Media New York 2016

Abstract for the amount of weight regain. Patients who regained weight
Background Although weight loss following laparoscopic were scheduled for GCTV.
sleeve gastrectomy (LSG) can be substantial, weight recidi- Results Twelve patients were excluded from the study.
vism is still a major concern. The aim of our work is to study Weight recidivism was reported in 9/89 patients (10.1 %)
early weight recidivism following LSG and to evaluate the [weight loss failure (n = 1), weight regain (n = 8)] and was
role of gastric computed tomography volumetry (GCTV) in almost always first recognized 1½–2 years after LSG. The
the assessment of patients experiencing early weight regain. amount of weight regain showed negative correlations with
Methods One-hundred and one morbidly obese patients un- preoperative body weight and body mass index (r = −0.643,
dergoing LSG were prospectively studied. Patients were P = 0.086 and r = −0.690, P = 0.058; respectively) and positive
followed up for 2 years. Those who presented with weight correlations with the distance between the pylorus and the
recidivism were counseled for dietary habits and assessed beginning of the staple line (r = 0.869, P = 0.005), as well as
with the residual gastric volume (RGV) on GCTV 2 years
after LSG (r = 0.786, P = 0.021).
* Ayman M. A. Osman Conclusions In the small group of patients who regained
aymanhady@cu.edu.eg; aymanhady@gmail.com weight, a longer distance between the pylorus and the begin-
ning of the staple line, as well as a higher RGV on GCTV
Mohamed H. A. Fahmy 2 years after LSG, were both associated with increased weight
dr.mohamed69@hotmail.com
regain. Gastric computed tomography volumetry with RGV
Mohamed D. Sarhan measurement holds promise as a useful research tool after
drsarhan777@hotmail.com LSG.
Ahmad Badran
aigbadran@hotmail.com Keywords Laparoscopic sleeve gastrectomy . Weight
Amr Ayad recidivism . Gastric computed tomography volumetry .
amrmayad@yahoo.com Residual gastric volume
Dalia K. Serour
daliakhaled80@yahoo.com
Hany A. Balamoun Introduction
hanyarmia80@gmail.com
Mohamed E. Salim
With the growing severity of the obesity epidemic over the
dr101moh@yahoo.com past few decades [1], the number of weight loss procedures
performed worldwide has increased significantly [2].
1
Department of General Surgery, Faculty of Medicine, Cairo Laparoscopic sleeve gastrectomy (LSG) is a relatively new
University, Cairo, Egypt and effective bariatric surgical procedure. It has recently
2
Department of Radiodiagnosis, Faculty of Medicine, Cairo gained popularity as a stand-alone procedure because of its
University, Cairo, Egypt relative simplicity, non-disruption of the gastrointestinal tract,
OBES SURG (2016) 26:2654–2660
lack of foreign body implantation and gastrointestinal anasto-
moses, nearly regular intestinal absorption, low incidence of
dumping syndrome, and 0 % risk of developing an internal
hernia [3–8]. LSG has been shown to be effective in reducing
excess weight by up to 70 and 60 % within 3 and 5 years,
respectively [9, 10].
Weight recidivism is an important issue and a concern for
many patients after bariatric surgery [11]. A devastating con-
sequence of such problem is the possible recurrence of
obesity-related co-morbidities [e.g., type 2 diabetes mellitus
(T2DM)] [12]. A recent systematic review has identified five
principal etiologies for weight recidivism representing nutri-
tional indiscretion, endocrine/metabolic alterations, mental
health issues, physical inactivity, as well as anatomic surgical
failure [13]. Owing to the relative infancy of the LSG proce-
dure, data on long-term weight recidivism following LSG is
still deficient [7]. The aim of this work is to study early weight
recidivism following LSG in terms of incidence, timing,
amount of weight regain, and possible contributing factors
as well as to evaluate the role of gastric computed tomography
volumetry (GCTV) in the assessment of patients experiencing
early weight regain.
Materials and Methods
One-hundred and one morbidly obese patients undergoing
LSG in Kasr Al-Aini Hospital, Cairo University, between
January 2011 and December 2012 were prospectively studied.
Patients were selected on the basis of strict inclusion and ex-
clusion criteria (Table 1). Body weight (BW) and BMI were
recorded preoperatively in all patients.
The surgical technique was standardized in all cases.
Following insufflation, four 12-mm trocars were introduced
(right and left upper quadrant trocars, an epigastric trocar, a
supra-umbilical trocar just to the left of the midline). A fifth 5-
mm trocar was inserted at the left anterior axillary line. After
placing the patient in anti-Trendelenburg position, the greater
omentum was dissected from the greater curvature of the
stomach, starting from a point 3–4 cm proximal to the pylorus
Table 1 Inclusion and exclusion
criteria used for patient selection Inclusion criteria
in our study
• Age of 16–60 years at the time of surgery
• BMI ≥40 or BMI ≥35 with a significant obesity-related
co-morbidity
• Failed adequate conservative program (diet, exercise
and/or medication) for at least 6 months
• Psychological stability/motivation and acceptance
of surgical risks
BMI body mass index
2655
all the way up till the angle of His using the ultracision
Harmonic scalpel. A 36-Fr bougie was then advanced orally
by the anesthetist and positioned in the pylorus. Gastric tran-
section was started 3–6 cm proximal to the pylorus using an
Endo-GIA linear stapler (Ethicon Endo-Surgery, Cincinnati,
OH). The stapler was first placed across the antrum and fired.
The distance between the pylorus and the beginning of the
staple line was recorded in every case. Sequential stapler fir-
ings, in the direction of the gastroesophageal junction, were
used to transect the stomach 1–2 cm from its lesser curvature
up to the angle of His. A 60-mm green or gold cartridge was
used for the first stapler firing, while blue cartridges were used
for subsequent firings. Finally, the entire staple line was care-
fully inspected and its integrity tested by a methylene blue test.
A 20-Fr nelaton drain was placed, and trocar sites were closed.
Patients were placed on a liquid-only diet for 1 month, then
a semi-solid diet for 2 weeks, followed by mashed food for
another 2 weeks. After that, a regular healthy diet was started.
Patients were instructed to come for follow-up at 6-month
intervals for at least 2 years. Body weight and BMI readings
were taken each visit. Early weight regain was defined as a
regain of ≥5 % of the BW that had been initially lost, occur-
ring 12–24 months after LSG. Patients who failed to lose
weight and those who experienced early weight regain were
all counseled for their dietary habits. In the latter group of
patients, the amount of weight regain (in kilograms) was cal-
culated by subtracting the lowest BW reading from the final
BW reading taken. Those patients were scheduled for GCTV
to measure the residual gastric volume (RGV). Guided by
Deguines et al. [14], we used the value of 225 cc as the
RGV threshold (the volume above which the risk of LSG
failure is high).
The correlations between the amount of weight regain and
each of the four parameters [preoperative BW, preoperative
BMI, distance between the pylorus and the staple line, volume
of the stomach on GCTV (RGV)] were studied. Logistic re-
gression analysis was then conducted in order to identify the
predictors of weight recidivism. Values in our study were
expressed as means or as numbers (%). Correlation between
variables was performed using Spearman rank correlation
Exclusion criteria
• Active alcohol or substance abuse
• Active gastric ulcer disease
• Gastroesophageal reflux disease (GERD) with
a large hiatal hernia
• Previous bariatric surgery
• Pregnancy or lactation
• Significant longstanding heart/lung disease or
other severe systemic disease
2656
coefficient (r). A P value <0.05 was considered statistically
significant whereas a P value <0.01 was considered statisti-
cally highly significant. Data was analyzed using SPSS for
Windows version 16.
Results
Out of 101 patients, 12 were excluded from the study [lost to
follow-up (n = 11), unexplained sudden death 7 months after
LSG (n = 1)]. All the remaining 89 patients completed at least
a 1-year follow-up [2 years (n = 48), 1½ year (n = 29), 1 year
(n = 12)]. Those 89 patients ranged in age from 18 to 55 years
(mean, 33.9 years) and included 75 females and 14 males.
Preoperative BMI ranged from 35.5 to 70.6 kg/m2 (mean,
49.2 kg/m2), and 27/89 patients (30.3 %) had a significant
obesity-related co-morbidity (T2DM, hypertension, or
dyslipidemia).
Data analysis showed that 80/89 patients (89.8 %) experi-
enced sustained weight loss after LSG. Remission of obesity-
related co-morbidities with discontinuation of hypoglycemic,
antihypertensive, or hypolipidemic medications was noted in
24/27 patients (88.9 %). Weight recidivism was reported in
nine patients (10.1 %), all of whom managed to complete a 2-
year follow-up. Of those, only one patient (1.1 %) demonstrat-
ed complete weight loss failure, without subsequent weight
regain. Meanwhile, eight patients (8.9 %) demonstrated early
weight regain. In all eight patients, weight regain was consis-
tent (i.e., ≥2 consecutive BW readings showing progressive
weight regain) and was almost always first recognized 1½–
2 years after LSG.
The amount of weight regain ranged from 10 to 45 kg
(mean, 21.6 kg). It showed negative—borderline insignifi-
cant—correlations with the preoperative BW and BMI
(r = −0.643, P = 0.086 and r = −0.690, P = 0.058; respective-
ly). Meanwhile, it showed significant positive correlations
with the distance between the pylorus and the beginning of
the staple line [r = 0.869, P = 0.005; Fig. 1], as well as with the
RGV on GCTV 2 years after LSG [r = 0.786, P = 0.021;
Fig. 2].
Nutritional counseling revealed that three out of the eight
patients who experienced weight regain had failed to adhere to
the outlined dietary regimens [uncontrolled binge eating
(n = 2), eating high calorie junk foods (n = 1)]. In one of the
remaining five patients, weight regain was clearly attributed to
hypothyroidism.
Based on available data, and in view of standardization of
the bougie caliber (36-Fr) in all cases, five items were ana-
lyzed with logistic regression analysis to identify the predic-
tors of weight recidivism (Table 2). Analysis showed that only
the distance between the pylorus and the staple line [odds ratio
(OR) = 6.679; 95 % confidence interval (CI) = 2.209–20.197;
P = 0.001] was an independent predictor of weight recidivism
OBES SURG (2016) 26:2654–2660
Fig. 1 Correlation between the amount of weight regain (kilogram) and
the distance from the pylorus (centimeter) [i.e., the distance between the
pylorus and the beginning of the staple line] in patients experiencing
weight regain [(n = 8), r = 0.869; P = 0.005)]
in our study patients (n = 89). Furthermore, the distance from
the pylorus demonstrated a highly significant positive corre-
lation with weight recidivism (r = 0.467, P = 0.001).
Discussion
Accumulating evidence obviously supports the superiority of
weight loss surgery over non-surgical treatments for manage-
ment of morbidly obese patients in terms of outcomes as
sustained weight loss, improved quality of life and prevention,
reduction, or resolution of co-morbidities (e.g., T2DM, dys-
lipidemia), as well as reduced overall mortality [15–17].
However, weight loss failure/weight regain is a well-
recognized issue after bariatric surgery [18, 19]. To date, no
clear consensus has been reached on a numerical definition for
weight recidivism (i.e., % weight regained). Weight recidi-
vism varies according to the length of follow-up and the bar-
iatric procedure performed, being especially prevalent after
procedures which lack an intestinal bypass e.g., sleeve gas-
trectomy (SG) [8, 13, 20]. In a long-term case series on SG, a
weight regain incidence of 19.2 % was reported [21]. Another
study reported an annual trend of mild weight regain after SG
through observing a progressive decrease in the %excess
weight loss (%EWL) at annual intervals [22]. Recently, it
has been estimated that approximately 5–10 % of SG patients
will eventually require a secondary operation to account for
weight recidivism [11]. This might involve either a redo (Re-
sleeve gastrectomy), conversion to another bariatric procedure
[e.g., Roux-en-Y Gastric Bypass, Bilio-pancreatic diversion
with duodenal switch], or adding an adjustable gastric band
[7, 8, 23, 24].
The underlying etiologies contributing to weight recidi-
vism are multi-factorial and often overlapping [13]. In order
OBES SURG (2016) 26:2654–2660
Fig. 2 Correlation between the amount of weight regain (kilogram) and
the volume of the stomach on gastric computed tomography volumetry
(GCTV) [residual gastric volume (RGV)] (cubic centimeter) in patients
experiencing weight regain [(n = 8), r = 0.786, P = 0.021]
to understand those complex etiologies, we need first to un-
derstand the SG multi-factorial mechanism of weight loss.
This mechanism involves, not only gastric restriction (de-
creased RGV), but also neuro-hormonal/metabolic changes
in the form of reduction of serum ghrelin levels, increased
paracrine effects of incretins [glucagon-like peptide-1 (GLP-
1), glucose-dependent insulinotropic polypeptide (GIP), pep-
tide YY (PYY)], increased serum bile acids, and decreased
insulin resistance, as well as accelerated gastric emptying
[25–27]. Thereby, weight recidivism following SG appears
to be related to a combination of technical, physiological,
and psychological factors (e.g., progressive sleeve dilation,
regulation of gut hormones, failure of nutritional behavior
modification) [24, 28]. It has been postulated that weight re-
gain could partly result from rising ghrelin levels, which might
be related to sleeve dilation [21, 29]. A significant negative
association between weight regain and nutritional counseling
attendance has also been reported [28]. Other risk factors for
weight recidivism include lack of physical activity and/or
follow-up [14].
Addressing weight recidivism after LSG necessitates a sys-
tematic approach to patient assessment that focuses on
Table 2 Logistic regression
analysis used to identify Variable
predictors of weight recidivism in
the study patients (n = 89) Age
Gender (female)
Preoperative body weight
Preoperative BMI
Distance between the pylorus and the beginning of the staple line
**P < 0.01 = highly significant
CI confidence interval, BMI body mass index
2657
contributing dietary, medical, surgical, and psychological fac-
tors [13]. No doubt, the first consideration that has to be ad-
dressed is adherence to the outlined dietary and lifestyle reg-
imens [30]. Another important concern that has to be consid-
ered is the possibility of gastric pouch dilatation [sleeve dila-
tion (increased RGV over time)] with subsequent weight re-
gain. This concern is not limited to the short-term but also
extends to the long-term [31]. Causes of sleeve dilation remain
unknown. However, it has been hypothesized that patient non-
compliance with outlined dietary regimens could lead to me-
chanical stretching of the gastric reservoir with subsequent
increase in its size, thus allowing consumption of a larger
volume of calories with a decreased satiety response.
Therefore, patients experiencing weight regain after LSG
should be investigated (e.g., upper gastrointestinal series) for
the possibility of sleeve dilation [13, 30–33]. Recently, it has
also been suggested that GCTV might help in predicting out-
comes after LSG, mainly by RGV measurement. A prospec-
tive study on 76 LSG patients showed that the risk of LSG
failure was high when the RGV exceeded the threshold of
225 cc and that a high RGV 34 months after LSG was an
important risk factor for weight recidivism [14]. Meanwhile,
Weiner et al. [31] suggested that a relatively large volume of
the gastric sleeve could be an important predisposing factor
for later dilation and weight regain. An association between
smaller volume gastrectomies—with a removed gastric vol-
ume <500 mL—and weight recidivism has also been reported
[14, 22].
In our study, weight recidivism was reported in nine pa-
tients (10.1 %) [weight loss failure (n = 1), weight regain
(n = 8)]. Weight regain was almost always first recognized
1½–2 years after LSG, a finding that is almost consistent with
Bohdjalian et al. [21]. The amount of weight regain showed
negative correlations with the preoperative BW and BMI i.e.,
the lower the preoperative BW/BMI, the larger was the
amount of weight regain. This agrees with Ochner et al. [34]
who reported that the total amount of weight loss after bariat-
ric surgery was smaller in patients with lower preoperative
BMI, despite the relatively higher %EWL. Logically, if those
patients with lower BMI regained weight, they would likely
regain a larger amount of weight. On the other hand, the
amount of weight regain showed a significant positive
Odds ratio 95 % CI P value
0.987 0.903–1.080 0.782
0.494 0.063–3.864 0.502
0.988 0.929–1.051 0.707
0.981 0.804–1.197 0.850
6.679 2.209–20.197 0.001**
2658 OBES SURG (2016) 26:2654–2660

A B

C D
Fig. 3 a–d Gastric computed tomography volumetry (GCTV) images for four different patients experiencing weight regain. Each image demonstrates
the residual gastric volume BRGV^ (cubic centimeter), 2 years after laparoscopic sleeve gastrectomy

correlation with the distance between the pylorus and the sta-
ple line i.e., the longer the distance from the pylorus, the larger
was the amount of weight regain. Furthermore, the distance
from the pylorus demonstrated a highly significant positive
correlation with weight recidivism in our study patients
(n = 89) and was an independent predictor of weight recidi-
vism in logistic regression analysis. These findings are con-
sistent with several studies which demonstrated that starting
the gastric transection at a point 3–4 cm proximal to the pylo-
rus would reduce the capacity of the antrum, thus allowing for
enhanced gastric emptying and weight loss [27, 35, 36].
Conversely, however, Bernstine et al.[37] preferred to start
the transection at a point 6 cm proximal to the pylorus, dem-
onstrating an unaffected gastric emptying function 3 months
after surgery, and emphasizing the importance of protecting
the anatomical and functional integrity of the gastric antrum.
We used the same technique of GCTV (CT gastrography)
that was used by Kim et al. [38] in their research study on 51
patients with different gastric diseases. In the small group of
patients who regained weight in our study, there was a signif-
icant positive correlation between the amount of weight regain
and the volume of the stomach on GCTV (RGV) 2 years after
LSG i.e., the higher the RGV, the larger was the amount of
weight regain. This association, together with the finding of a
high RGV (above the threshold of 225 cc) in the two binge-
eating patients, suggest that progressive sleeve dilation could
result in weight regain. However, the correlation between the
amount of weight regain and the RGV on GCTV does not
ultimately imply causation between those two variables due
to the lack of GCTV data on patients who did not experience
weight regain. Furthermore, finding a low RGV (<225 cc) in
5/8 patients experiencing weight regain is a clear evidence that
OBES SURG (2016) 26:2654–2660
Fig. 4 Gastric computed tomography volumetry (GCTV) with 3D reconstruction for one of the patients experiencing weight regain. The image
demonstrates the residual gastric volume BRGV^ (cubic centimeter), 2 years after laparoscopic sleeve gastrectomy
other factors could still contribute to weight recidivism with-
out necessarily causing sleeve dilation e.g., eating high calorie
junk foods, hypothyroidism (Figs. 3 and 4).
Finally, we can conclude that, in the small group of patients
who regained weight in this study, the distance between the
pylorus and the beginning of the staple line, as well as the
RGV on GCTV 2 years after LSG, were both associated with
increased weight regain. Gastric computed tomography
volumetry with RGV measurement holds promise as a useful
research tool after LSG. Unfortunately, the small number of
patients experiencing weight regain, together with the lack of
GCTV data on patients who did not experience weight regain,
has limited the conclusions that can be drawn from this study.
Further studies with larger sample size are thus required in
order to further investigate the Bweight recidivism^ problem,
as well as the value of RGV measurement—if any—in pa-
tients who experience sustained weight loss after LSG.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
2659
Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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