Evidence-Based Classification for Post-bariatric Weight Regain from a Benchmark Registry Cohort of 18,403 Patients and Comparison with Current Criteria

Abstract

Introduction: There is a need for a standardized, evidence-based classification of post-bariatric weight-regain, to investigate and compare revision procedures and to advice and treat patients in an evidence-based way.

Methods: We used standard deviations (SD) of the highest (1-2 years) and latest (> 2 years) percentage total weight loss (%TWL) results after primary bariatric surgery from the Dutch Audit for Treatment of Obesity (DATO) bariatric registry as benchmarks for (above) average (≥ - 1SD), poor (- 1SD to - 2SD) and insufficient (< - 2SD) weight loss. Weight regain maintaining (above) average weight loss was called grade 1, weight regain towards poor weight loss grade 2, towards insufficient weight loss grade 3, with subgrades 2a/3a for below average weight loss from the start, and 2b/3b for weight regain from (above) average to below average weight loss. Patient characteristics and diabetes improvement/impairment were compared. Sensitivity and specificity of 14 existing weight regain criteria were calculated.

Results: We analyzed 93,465 results from 38,830 patients (77.1% gastric bypass, 22.5% sleeve gastrectomy). The - 1SD thresholds for early and late weight loss approximated 25%TWL and 20%TWL, the - 2SD threshold for late weight loss 10%TWL. Weight regain could be analyzed for 18,403 patients (2.5-5.2 years follow-up). They regained mean 6.7 kg (5.4%TWL), with 66.8% grade 1 weight regain, 7.2% grade 2a, 7.4% grade 2b, 2.1% grade 3a, and 0.6% grade 3b. There were significant differences in comorbidities, gender, age, weight regain, diabetes impairment, and diabetes improvement across grades. Weight regain criteria from literature were extremely divers. None had high sensitivity.

Conclusion: The DATO classification for post-bariatric weight regain combines the extent of weight regain with evidence-based endpoints of weight loss. It differentiated weight regain maintaining (above) average weight loss, two intermediate grades, gradual weight regain with below average weight loss from the start (primary non-response) and steep weight regain towards insufficient weight loss (secondary non-response). The classification is superior to existing criteria and well supported by evidence.

Keywords: Bariatric surgery; Classification; DATO; Diabetes; Endoscopy; Failure; Gastric bypass; IWL; Impairment; Insufficient weight loss; Non-responder; Revision procedure; Sleeve gastrectomy; Total weight loss; WR; Weight correction; Weight loss; Weight recurrence; Weight regain; Weight reoccurrence.