National Journal of Health Sciences, 2024, 9, 162-167 162

Research Article
Weight Regain Following Laparoscopic Sleeve Gastrectomy in Morbid
Obesity
Allauddin1,*, Ghulam Siddiq2, Muhammad Sohaib Khan3, Gulalai Rehman4, Tehreem Zahid5
1
Surgery Department, Bolon Medical College, Quetta, Pakistan.
2
Surgery Department, Shifa International Hospital, Islamabad, Pakistan.
3
Surgery Department, Shifa Tameer- e-Millat University, Islamabad, Pakistan.
4
Nutrition Department, Baluchistan Institute of Nephro-Urology, Quetta, Pakistan.
5
Research Department, Shifa International Hospital, Islamabad, Pakistan.

Abstract: Background: Sleeve gastrectomy is the common bariatric procedure done for morbid obesity, but, there are limited studies avail-
able, specifically from South Asia. In Pakistan, no such study has been done before.
Objective: The main outcome of the study was Excess weight loss (EWL) and Weight Regain (WR) after Laparoscopic sleeve gastrectomy and
to see improvement in co-morbid associated with morbid obesity.
Materials and Methods: The patients who underwent Laparoscopic sleeve gastrectomy for morbid obesity were analyzed retrospectively.
From June 2017 to June 2019, in a tertiary care hospital in Pakistan. Patients whose BMI exceeds 40 kg/m² or falls between 35-39 kg/m² accom-
panied by one or more comorbidities, and have undergone at least three years of follow-up. Redo procedures of LSG were excluded. Data was
obtained from patients’ charts and hospital database, and last follow-ups were done by telephonic survey.
Result: In 171 patients 56.72% were female. Mean BMI was 48.5kg/m2. %EWL was 77.90% and total body weight loss was (% TBWL ) 39.48.
Weight regain WR was 25.7 %, Regain of > 25%EWL was 14%. Increase in BMI >5/kgm2 was 17.5%. DM remission was 70% (28 pts) while in
30% (12) improved. Hypertension in 54.28% (38) pts improved and in 45.71% (32) hypertension completely resolved. Obstructive sleep apnea
was resolved completely by 93.6 % (44). Osteoarthritis improved (by 78.4 %). GERD was developed in vivo in 14% of patients postoperatively.
Lap chole for symptomatic gall stones was done in 9.35% of post-lap sleeve gastrectomy patients during follow-up.
Conclusion: Weight regain after sleeve gastrectomy was significant, but, still the post-operative co-morbid remission was promising.
Keywords: Sleeve gastrectomy, Weight regain, BMI, Comorbid resolution, Type 2 DM, GERD, Obstructive sleep apnea, Excess weight loss,
Fatty liver disease.

INTRODUCTION obesity [3]. However, weight regains after sleeve gastrectomy

is a well-known complication, and is relatively high in different
In the twenty-first century, changes in population characteristics, series [4].
increase urbanization, calorie-dense fast-food availability, and
digitalization greatly affected the human lifestyle and food habits Different definitions are used for Weight regain, (Table 1)
leading to an increase in obesity. Most of the adverse effects of [5]. Long-term studies have reported the incidence of weight
obesity are noncommunicable illnesses that are preventable by to regain following SG is significant. One study reported 5 to
preventing Obesity itself [1]. According to World Health Orga- 39 % [6]. Weight regain leads to the recurrence of obesity-related
nization (WHO), more than 650 million people were obese glob- comorbid [7]. The weight regain after sleeve gastrectomy is not
ally in 2016 [2]. fully understood, but seems multifactorial. An integrative review
showed: 1) remnant antrum size, 2) bougie size, 3) increase level
Obesity is related with various co-morbids including metabolic of appetite hormone, 4) poor lifestyle, and a lack of exercise are
syndrome, type 2 DM, HTN, Cardiovascular diseases osteoar- possible factors [8]. South Asian like India and Pakistan differ
thritis Respiratory problems, psychological impact, depression, from western populations in lifestyle body composition, nutri-
and gastrointestinal and breast cancer are thought to be associ- tion intake, lower lean body mass, increase visceral fat. South
ated with Obesity. Asian have high visceral fat, this is so-called central obesity
leads to a higher rate of metabolic syndrome, Insulin resistance,
Sleeve gastrectomy, founded in 1999, has become a famous ther-
and an increase rate of cardiovascular diseases among Asian
apeutic modality for surgical treatment of different degrees of
populations [9]. The purpose of this study was to see long-term
* Address correspondence to this author at the Surgery Department, Bolon results regarding excess weight loss (EWL) and weight regain
Medical College, Quetta, Pakistan. Email: [email protected]
(WR) after laparoscopic sleeve gastrectomy.

doi.org/10.21089/njhs.93.0162
© 2024 NIBD Publications www.njhsciences.com
163 National Journal of Health Sciences, 2024, Vol. 9. No. 3 Allauddin et al.

Table 1. Criteria of Weight Regain after Bariatric Surgery. Weight Loss

Definition %TWL= Weight loss/initial weight x100.
1. An increase of more than 10kg from nadir weight. Percent of Excess weight loss (%EWL) was calculated by using
2. An increase of more than 25%EWL from nadir weight. the formula.
3. An increase in BMI of 5 kg/m2 from nadir. %EWL=pre-operative weight--post-operative weight/pre-oper-
4. An increase of more than 15% total body weight from nadir. ative weight-ideal weightx100.
5. Weight regain to a BMI > 35 kg/m2 after successful loss. STATISTICAL ANALYSIS
6. An increase of >15% of the lowest postoperative weight.
Data analysis was done using by SPSS version 21.0. For contin-
Kg: Kilogram; %EWL: Percent excess weight loss; BMI: Body mass index; m: Meters;
T2DM: Type two diabetes mellitus.
uous variables, results were shown as mean and standard devi-
ation (SD). For continuous variables comparison between the
MATERIALS AND METHODS groups was done using paired t-test, while chi square was run
for categorical variables. Linear and logistic regression analyses
The study was approved by institutional review board. (Ref: were performed to evaluate the effects of various compounders
19-22.) The data was collected and analysed from a prospec- like age, gender, bougie size, BMI. The p-value < 0.05 was con-
tively maintained database also files of patients were reviewed, sidered significant.
from June 2016 to June 2019. Who were followed in clinics
and the last follow-up was done by telephonic calls and what’s
app. The age was between 18 to 70 years and BMI >40 kg/m2 or RESULT
35-39kg/m2 with one or more obesity-related co-morbid. There were 205 patients who underwent laparoscopic sleeve
The patients with Redo sleeve gastrectomy and follow-up less gastrectomy for morbid obesity, between June 2016 and June
than 3 years were excluded. Also, patients with gastroesophageal 2019. 171 patients had complete follow-up, were included in the
reflux disease/Hiatus hernia, acute psychosis, alcohol addiction analysis. The 34 patients excluded from the study were 7 patient
or drug abuser were excluded. refused to participate, 12 patients follow up was incomplete and
15 patients were not available. There were 97(56.7%) female and
Preoperatively all relevant work up was done, upper gastro intes- 74(43.3%) male patients. The mean age was 35.5 years (±9.67).
tinal endoscopy has been performed in selective patients with The mean and standard deviation of preoperative weight was
symptoms of GERD to assess and R/O possible hiatus Hernia. 134.7(±30.38), and BMI was 48.53(±9.40) (Table 2).

Super obese patients were put on 2 weeks of pre-op dieting to Table 2. Demographic Data Before LSG.
reduce liver size.
Value % (SD)(range)
Data Collection Gender (Female/Male) 97/74 56.7%43.3%
Mean (age) 35.57 (± 9.6)
At pre-formed proforma, all the data were collected from the file
Median (BMI) 48.53 (± 9.40)
and other recorded databases, including demographic intra-op-
erative and post-operative results, were obtained, follow-up Mean Weight (kg) 134.71 (± 30.38)
recorded and then each patient was called on the phone as the last Mean Height (in meters) 1.663 (±.101)
follow-up to June 2022, for the of lowest recorded weight and
current weight, any complications, and improvement or recur- Hypertension was present in 40.93%(70), Diabetes was pres-
rence in co-morbid was recorded. If got weight regains (WR) or ent in 23.4%(40), Osteoarthritis was prevalent in 84.2%(144),
insufficient weight loss, the reason was inquired about lifestyle snoring in 70.8%(121), Obstructive sleep apnoea was present
dietary habit, exercise. in 25.7 %(44). Exertional dyspnea in 84.2%(144). Low back
ache 78.9% (135). Only 6.4% patients were regular exercise,
Weight Regain rest were having sedentary lifestyles. In our cohort, 18.7%(32)
were smokers.
Percent %WR was defined as currently recorded weight-low-
est recorded weight/pre-op weight-lowest recorded weight. We Our mean operating time was 89.87 min (±35.75). We used 36
have used three common formulas used nowadays in literature F bougie and the distance from the pylorus was 4-6 centimetres.
[10] . We achieved average follow-up of 4 years. 85% (3 years), 38.6%
(4 years), and 11.7% (5 years) (Fig. 1).
[1] Regain of > 10kg from nadir weight.
[2] Regain of > 25%EWL from nadir weight. The mean percent of excess weight loss (%EWL) was
[3] Regain >5 BMI points from the nadir BMI. 77.90(±20.11). Percent of total weight loss (%TWL) 39.48(±
Weight Regain Following Laparoscopic Sleeve Gastrectomy... National Journal of Health Sciences, 2024, Vol. 9. No. 3 164

12.16). Change in mean BMI was 19.80 (±9.3). The excess resolved. Obstructive sleep apnoea was present in 27.48%
weight loss was more than 50% in 88.9 % (152 patients), while (47). 93.6 % (44) OSA completely resolved while in 8.5% (4)
11.1 % (19 patients.) EWL was less than 50% (with insufficient improved. Osteoarthritis was present in 84.2% (144) improved,
weight loss). in 78.4 % (113) and resolved in 21.52% (31). GERD was devel-
oped in vivo in 14% (24) patients postoperatively and a his-
Follow-Up in Years
tory of hair loss in 30% (52) temporarily which later subsided.
Polycystic ovary syndrome (PCOS) was present in 13.45% (23
pts PCOS resolved in 18 pts 78.26%. Lap cholecystectomy was
12% done in 9.35% (16) pts during follow-up for symptomatic gall
stones after sleeve gastrectomy (Table 5).
3 Years
4 Years Table 5. Clinical Characteristics of the Patients undergoing
50%
5 Years Lap Sleeve Gastrectomy.
38%

Post-operative
Pre-op- %(n)
Characteristics erative
%(n) Resolved Improved
Fig. (1). Follow-Up
40.93%
Weight Regains (WR) Hypertension 45.71% (32) 54.28% (38)
(70)
According to formula 1 weight regain>10 kg from nadir weight 23.4%
Diabetes 70% (28) 30% (12)
was 25.7 % (44). 2) Regain of >25%EWL from nadir was 14% (40)
(24). 3) Change in BMI >5 kg /m2, 17.5% (30) respectively. We Obstructive
27.4%
achieved above weight regains according to 3 formulas at an Sleep Apnea 93.6% (44) 6.3% (3)
(47)
average follow-up of 4 years (Table 3). (OSA)
84.2%
Table 3. Weight Regain in our Cohort according to Six Stan- Osteoarthritis 21.52% (31) 78.4% (113)
(144)
dard Formulas in the Literature.
Polycystic ova- 13.45%
78.26% (18) 21.7% (5)
Definition of Patients with Weight Regain n (%) ries (PCOS) (23)
1. An increase of >10 kg from nadir 44(25.7%)
2. An increase of more than 25%EWL from nadir 24(14%) DISCUSSION
3. An increase in BMI of 5 kg/m2 30(17.5%) Sleeve gastrectomy is the common bariatric procedures done for
4. An increase of >15% of total body weight 22(12.9%) obesity [11]. There are many are many studies in the literature
from nadir addressing the results of Lap sleeve gastrectomy in obesity, but
5. Weight regains to a BMI >35kg/m2 after suc- 20(11.7%) scarce data available from Asia and none from Pakistan. This
cessful weight loss study is the first one in Pakistan to look for the results of laparo-
scopic sleeve gastrectomy in obesity, especially in the context
6. An increase of >15% of the lowest postoper- 35(20.5%)
of excess weight loss (EWL) and weight regain (WR). And also
ative weight
to see improvement or resolution of obesity-related co-morbid
like diabetes, and other co-morbidities. Our study includes 205
The weight regain was higher in female (Table 4).
patients. We achieved 83.41% (171) patients) complete fol-
Table 4. Weight Regains according to Gender using >10 kg low-up.
From Nadir.
In our study female patients were dominant at 56.7%. like in
Sex n (%) other studies [12, 13]. The mean age was 35.5 yrs. which shows
the majority were young and middle age. The major co-mor-
Male 17(22.9%)
bid were Diabetes Mellitus, hypertension, Osteoarthritis, and
Female 27(27.8%) obstructive sleep apnoea. Successful surgery for weight loss
Total 44(25.7%) was defined as % TWL more than 10% or % EWL mora than
50 %. We had a mean percent of weight loss (% TWL) of 39.48
In this cohort, DM was present in 23.4% (40). 70 % (28) DM (± 12.46), Excess weight loss (% EWL) of 77.79% (±20.11).
resolved completely while in 30%(12) patients improved. Our results were in accordance with other studies %TWL was
40.93% (70 patients) were hypertensive. 54.28% (38) pts 31.3±8.9 and %EWL 76.3±25.5 and a similar study by Garg H,
improved, while 45.71% (32 patients) hypertension completely et al. %EWL was 72%±22.35 (25). There was an 88.9% (152
165 National Journal of Health Sciences, 2024, Vol. 9. No. 3 Allauddin et al.

pts) %EWL was more >50% while 11.1% that is 19 pts. %EWL or secondary. If the total capacity of the sleeve is more than 250
<50% [14]. ml, it will result in primary failure. Gradual increase in the stom-
ach size over time with increase ghrelin level lead to increase
Weight regain is a known late complication after weight loss appetite resulting in secondary failure. Other factors responsible
following laparoscopic sleeve gastrectomy [15]. Insufficient for weight regain, calorie dense diet and sedentary life style. As
weight loss is defined as achieved less than 50% EWL [16]. South In our patients there was lack of exercise, increase intake
Weight regain and insufficient weight loss has different causative of carbohydrate poor regular follow-up and noncompliance.
mechanisms and management [17].
The incidence of gall stones was higher, for which laparoscopic
Weight regain (WR) is one of the complication after sleeve gas- cholecystectomy was done in 9.35% of the patients postopera-
trectomy, like in any other bariatric surgery [18] Weight Regain tively, which is comparable to a study by Hasan et al. [32].
was the main outcome in our study, it was 25.7% by applying
the formula Regain >10kg from Nadir weight. 14% by using LIMITATION
regain>25% EWL and 17.5% by Change in BMI >5 kg /m2,
according to the standard formula used. This is comparable with The limitation of this study was, last follow-up was performed
the literature Shivanshu Misra et al. [19] weight regain was on the telephone, which, may be affected by recall bias, and the
17.6% at 3 years and 39.1 % at 5 years. Similarly according to comorbid improvement was analyzed on a patient narrative of
Noel et al. [20] weight regain was 41.7% in long-term follow-up. discontinuing medicine and therapy prescribed by other phy-
In a cross sectional Saliba et al. reported weight regains 5.7% by sicians. Also, some cultural norms of eating excess meat and
two year follow up [21]. refined carbohydrates especially in Pushtoonkhwa (The north-
west region of Pakistan), was not taken into account, which was
Bohdjalian et al. reported 19.2% weight regain after follow up evident from the reasons of weight regain patients interviewed.
for five years [22] ,while another meta-analysis showed that the
percentage of weight regain was 27.8% at seven years follow
up [23].The average follow-up of our cohort was 4 years rang- RECOMMENDATION
ing from 3 years to 5 years. And WR was 17.6 to 25.7%. The Further research with larger sample size and multicentre studies
other secondary outcome of our study like DM was resolved are recommended to enhance the better extrapolation of results.
completely by 70% and improved by 30% compared with
the literature [24], a study by Shivanshu Misra et al. showed
71.4 % diabetes remission and 21.4 % improvement [25]. CONCLUSION

A study by Wang X, et al. at 3 years follow-up, the percent- Laparoscopic sleeve gastrectomy successfully reduce weight in
age of remission was (71.4%) while improvement was found morbid obesity, with good results in remission in T2DM and the
at (17.8%) [17, 26]. There were 70 patients (40.93%) with resolution obesity related comorbidities Hypertension, Obstruc-
hypertension in our cohort. Hypertension improvement seen in tive sleep apnea, Osteoarthritis, and fatty liver disease. However
(54.28%) 38 patients and study by Piotr K. Kowalewski et al. Weight regains (WR) after Laparoscopic Sleeve gastrectomy is
[27]. Post sleeve gastrectomy, 28% hypertension completely a clinical problem. It is well reported in the literature and obvi-
resolved and in 31% patients improved. In another study by ous from this study and needs to be addressed in future studies
Wang X, hypertension was resolved by 43.1%. regarding change in techniques or modifying procedure.

In a study by Hamilton et al. obstructive sleep apnea is found in ABBREVIATIONS

58% obese patients [28]. Severe OSA is associated with a high
risk of cardiovascular diseases, stroke and sudden death. Weight BMI: Body Mass Index.
loss following Sleeve gastrectomy will result in improvement of DM: Diabetes Mellitus.
Obstructive sleep apnea. In our study OSA completely resolved EWL: Excess Weight Loss.
in. 90.9 % 40 patients, while in 8.5 % 4 patients Improved.
GERD: Gastroesophageal Reflux Disease.
Continuous positive air way pressure was not needed post-op-
eratively. 50.7% patients had OSA preoperatively, after LSG LAG: Laparoscopic Sleeve Gastrectomy.
100% improvement was seen. Osteoarthritis was in 84.2(144) OS: Osteoarthritis.
improved in 78.4 %(113) and resolved in 21.52% [22, 29]. OSA: Obstructive Sleep Apnea.
GERD was developed in vivo in 14% of our cohort which is in PCOS: Poly Cystic Ovary Syndrome.
literature (range from 11-33%) [12]. Postoperatively, history of
PTS: Patients.
hair loss in 30% temporarily was later on subsided. Polycystic
ovary syndrome (PCOS) symptoms like menstrual irregularities, SD: Standard Deviation.
hirsutism, and hormonal abnormalities resolved in 78.26% but TBWL: Total Body Weight Loss.
no clear-cut improvement in infertility could be identify as a WR: Weight Regain.
result of bariatric surgery without a case controlled or random- WHO: World Health Organization.
ized studies [30, 31]. Causes of weight regain are either primary
Weight Regain Following Laparoscopic Sleeve Gastrectomy... National Journal of Health Sciences, 2024, Vol. 9. No. 3 166

AUTHORS’ CONTRIBUTION Surg Obes Relat Dis 2019; 15(6): 995-1005.

●● Allauddin: Design and Main idea. [9] Iliodromiti S, McLaren J, Ghouri N, et al. Liver, visceral and
subcutaneous fat in men and women of South Asian and white
●● Ghulam Siddiq: Concept of the study. European descent: A systematic review and meta-analysis of new
and published data. Diabetologia 2023; 66(1): 44-56.
●● Muhammad Sohaib Khan: Proforma designing.
[10] Nedelcu M, Khwaja H, Rogula T. Weight regain – how to define
●● Gulalai Rehman: Data analysis, Nutritional follow-up. it? Surg Obes Relat Dis 2016; 12(5): 1-2.
●● Tehreem Zahid: Follow-up, Data analysis. [11] Chopra A, Chao E, Etkin Y, et al. Laparoscopic sleeve gastrec-
tomy for obesity: Can it be considered a definitive procedure?
CONFLICT OF INTEREST Surg Endosc 2012; 26(3): 831-7.

Declared none. [12] Capoccia D, Guida A, Coccia F, et al. Weight regain and diabetes
evolution after sleeve gastrectomy: A cohort study with over 5
ACKNOWLEDGEMENTS years of follow-up. Obes Surg 2020; 30(3): 1046-51.

Declared none. [13] Magro DO, Geloneze B, Delfini R. Long-term weight regain
after gastric bypass: A 5-year prospective study. Obes Surg 2008;
18(6): 648-51.
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Received: October 23, 2023 Revised: April 28, 2024 Accepted: May 11, 2024

© 2024 National Journal of Health Sciences

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