On this occasion, we will talk about a topic that is very important for both people who are considering weight loss surgery and for your surgeon if he/she is interested in reaching your goals and being a success story.

If your surgeon shows interest in your success, it is because he/she really cares that you as the patient achieve your goals and that at the end of the day, you will be his cover letter to other people, so it is a win-win situation for both parties.

Definition of failed bariatric surgery

What do we call in bariatric surgery a "failed weight loss surgery"? It is the one that fails to maintain a 50% or greater excess weight loss. The elapsed time varies, but in general, the studies that evaluate results are based on the results of up to 5 years after surgery. The issue of weight regain after weight loss after surgery is even more relevant, but this will be discussed in another article; however, you will see that in the current article, topics are also applied to those who regain weight.

First of all, we should mention what we said to every person who is looking for a gastric sleeve surgery or some other bariatric procedure. "Bariatric surgery is not magic!" We literally say this to all of our potential patients because, unfortunately, there is the wrong idea in certain people who, once they've had weight loss surgery, they believe it will solve all their difficulties with their inability to lose weight.

Although it is true that in all patients whose body mass index (BMI) is higher than 35, their body enters a state of "self-protection" in which it is difficult for them to lose weight easily and, above all, to maintain this loss due to this system of self-regulation in which your body enters (a complex process in which many hormones and systems that are out of the interest to most of our readers, so we will not delve into this).

The body of an obese person (with BMI 35 or higher) adapts to being at that weight and at certain body fat percentage, so when you try to lose weight through diet and exercise, it is more challenging to achieve the goal than a person with a BMI less than 35. The only thing that has so far managed to break this vicious cycle of loss and regain is precisely bariatric surgery, which allows a "reset" of the tendency of self-regulation.

Having said this, it is a fact that almost anyone who intends to lose weight will achieve it, however here the key is to be able to maintain such weight loss for a prolonged time, something that by statistics shown in various studies has been seen to be extremely complicated and this is where bariatric surgery demonstrates its great benefits. Bariatric surgery allows the patient to lose weight, but most importantly, maintain such loss, as long as he/she makes the necessary changes in lifestyle and dietary habits during the immediate and mediate postoperative periods. This is where it is vital to be aware that surgery is not magic, but an excellent tool that the patient must learn to use for life if what he/she seeks is to reach the target weight and maintain it.

So, if the patient is doing “the right thing” after surgery, why could it happen that he/she is not losing enough weight? Here are some of the possible reasons.

Initial phases (Immediate postoperative)

In the immediate postoperative period, one of the most frequent reasons that prevent the scale from moving is fluid retention, so in the first days and even weeks of postoperative period, it is expected that your body will retain a more significant amount of fluid than usual; this is simply because it is in the recovery phase, healing the “aggression” that it received during surgery, because at the end of the day, the body only knows that it must heal the wounds (of the abdominal wall and the stomach and/or intestines) and this causes a moderate inflammatory process that promotes fluid retention.

In the first weeks of post-surgery, if you are following the instructions of your bariatric surgeon, the weight loss should occur, and if not, it is most likely due to what despite believing that you are following all the directions, there must be an occasional interpretation error, such as:

• Eat food too fast
• Ingesting smaller amounts of protein than recommended
• Eating food and liquids at the same time
• Not chewing enough each and every bite
• Eating foods or liquids that are high in carbohydrates or calories
• Not drinking enough water
• Eating processed foods
• Not taking the recommended nutritional supplements and vitamins
• Ingesting liquids with high caloric content (juices, sweetened tea, milkshakes, ice cream, etc.)

Late phases (months after the procedure)

In the months after surgery (approx. 3 to 18 months) is when almost all of the excess weight loss is achieved, if this does not happen it is very likely that you are doing some of what was previously listed or that you are simply falling onto new or old habits such as not monitoring the nutritional and caloric value of food and liquids ingested, eating out of hours, overeating, you are not exercising enough or at all.

It is common to see patients who do not lose enough weight or are dissatisfied with their weight loss have fallen into one or more of the previously described situations or have not been adequately informed about what expectations to have with their surgery.

It is essential to clarify that there is no bariatric procedure that achieves 100% loss of excess weight, name it gastric bypass, gastric sleeve, mini bypass or one anastomosis bypass, gastric band, gastric plication, even more aggressive procedures such as the duodenal switch, SADI, etc., none achieve a loss of all excess weight in the vast majority of cases.

The statistics on the percentage of weight loss vary, but based on the literature of recognized bariatric associations (https://asmbs.org/patients/bariatric-surgery-procedures) is as we show below:

Approximate percentage of weight loss according to the procedure:

• Gastric Sleeve 60 to 70%
• Gastric Bypass 60 to 80%
• Gastric Band 40 to 50% variable average of 30 to 50%
• Mini Gastric Bypass 60 to 70%
• Duodenal Switch / Biliopancreatic Bypass 60 to 85%

As you can see, the loss is not 100% but enough to achieve relevant changes in the patient's health status. It should be noted that when the patient reaches these weight loss percentages, it is because he/she followed the instructions to the letter and if wishes to lower more without leaving all the "responsibility" to the procedure, he/she can achieve it but must try harder than he/she has done to achieve it.

Those patients who even shortly after surgery (12 to 24 months) have not lost the weight they expected, should, as mentioned above, review the following details:

• If they have not been correctly informed on the weight loss expectations with the procedure to which they were subjected.
  
  
• If they have not made the necessary changes in lifestyle and dietary habits in a tangible way.
  
  
• If they require a second bariatric procedure to increase the percentage of loss (this is necessary in a good number of cases of patients with super obesity BMI 50 or more).
  
  
• Define whether your certified surgeon was the best possible choice, or if the surgical technique was not correct, is a rare but probable factor.
  
  
• We must take into account that each person is different, so the results are variable, and many factors come into play.

How to lose weight adequately

Even though this topic is about insufficient weight loss, the real objective of this article is to help the patient to achieve his/her goals, so we will list the counterpart of what factors can favor adequate weight loss after bariatric surgery:

1. The most essential thing, in our opinion, is to correctly choose your bariatric surgeon, who should be a real expert in the procedure since it plays a crucial role. A technically deficient surgery represents a health risk and a risk of not obtaining optimal final results.
   
   
2. Keep close contact with the surgeon, ideally, and if the situation allows it, follow-up for not less than 6 months and preferably for life, although with increasingly extended periods of time between appointments.
   
   
3. Assimilate that you as a patient are assuming a commitment with yourself to take care of your surgery and your investment; this means making the necessary changes in your lifestyle and eating habits, in a few words, change the relationship that you have with food.
   
   
4. Integrating an exercise routine, which should not necessarily be strenuous, can be something as simple as walking or jogging for 20-30 minutes 3 times per week, although as expected, the more exercise you do, the better results you will get.
   
   
5. If you fail to establish the habit of exercise, it is recommended that you seek support with a trainer/physical trainer to have personalized help.
   
   
6. It is also important to consider continuing with psychological support, which has been shown to be very efficient for patients suffering from a disorder before or after surgery.
   
   
7. Nutrition advice with either a member of your bariatric surgeon team or someone of your choice, this advice will take your weight off in terms of being aware of counting and recording everything you eat; It is proven that patients who keep a diary have better final results.
   
   
8. Check that none of the medications that you usually take is the reason why you do not lose weight or why you retain fluids. In this regard, in the end, if it is a medication that you need for a particular disease and you cannot stop it, the dose or type of drug could be modified with the advice of your attending physician.
   
   
9. Watch your sleep pattern, if you have problems with this, it is likely to affect your weight loss. There are experts in the area of ​​sleep disorders that could help you change this problem.
   
   
10. Stress is another factor that you should seek to avoid or relieve since it also contributes to less weight loss.
    
    
11. Make sure to create a favorable environment for your new lifestyle, avoiding people or situations that could boycott your progress.

One tip that we usually give our patients is that if you find yourself in this situation or are looking to avoid reaching it, it is that you should do a self-analysis of your person, your life and your environment, without bias, without prejudice and see things objectively. More than once, it has been my turn to deal with patients who seek to justify the low weight loss with excuses and situations that only reflect that they are not being aware that it is they themselves who boycott their progress.

You must somehow be selfish even if necessary and focus on your person to make a solid enough commitment to yourself, so you can reach your goals.

You must remember that it is not only a critical step what you are taking but a new life that you are looking to have and with that perspective you will have to face the challenge that the changes that you must make represent, I see it as when an addict makes the decision to stop its vice definitively, it can be that difficult for an obese patient to change the relationship he/she has with food and everything that food represents in his environment.

Now it's your turn, tell us, what are your fears and expectations regarding weight loss surgery?

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