When gastric bypass patients regain some of their original weight loss, it is usually due to some eating behavior problems and some mechanical problems:

 

Eating behavior problems which cause weight gain:

1. drinking with meals;  this makes the food flow through the pouch readily allowing one to eat much more food. 

2. eating soft, slider type of foods like soup, yogurt, smoothies, that also flow readily through the pouch.

 

Mechanical problems which might cause weight gain:

1. abnormal connection to lower stomach;  very rare less than 1% of patients. usually in patients who had forgotten the recommendation to avoid aspirin compounds.

2.  large outflow opening.  This is very common (probably 80% of patients have a slight enlargement of the opening from the pouch to the intestines.  Hence, food tends to go through too quickly, leading to more hunger and allowing more calories to be eaten. 

 

How do we diagnose the issue?

A barium burger is a solid meal mixed with barium that shows us the size of the pouch and the emptying at 30 minutes.  If most has emptied by that time, it almost always means that the pouch outlet is too large. 

 

What are the options to narrow the outlet?

 

ROSE procedure;  this involves a disposable scope which allows for suturing inside the pouch to narrow the outlet.  Recent report at ASMBS meeting showed approximate 18-20% loss of excess weight at one year.  There is no code for this procedure and the costs are around $12,000.

 

Sclerotherapy;  this involves the use of a scar-forming material (sodium morrhuate), which can be injected to narrow the outflow.  This is done endoscopically in a GI lab.  Patients go home in about one hour and are back at work the next day.  Three prior reports suggest that 2/3 of patients can lose about 20% of excess weight.  We have performed over 50 procedures without any problems.  95% of patients have lost weight (10-50 pounds).  90% of patients feel significant restriction to solid foods after the procedure.  To achieve good results, it is important to maintain good eating behavior after the procedure:  eat solids, avoid slider foods, avoid drinking with meals, avoid high calorie snacks.  Beginning July 15, the practice will file insurance and attempt to obtain reimbursement using specific new codes.