Banded Gastric Bypass

“ Banded gastric bypass appears to result in sustained weight loss, perhaps greater than that achieved by standard RYGB. ”

Buchwald

Banded Sleeve

Banded Sleeve

History of the Banded Gastric Bypass

Since the introduction by Mason and Ito in 1966 of the loop gastric bypass, this procedure has proved consistently the most successful treatment for the greatest number of morbidly obese patients. It is also the most well researched bariatric operation, with more than 7.800 peer reviewed publications.

However, RYGB is also related to specific complications and long term weight regain.

Over the years several modifications have been suggested to the RYGB of which the banded gastric bypass seems to be the most effective, with superior weight loss results and similar or even improved complication rates.

In the early 90’s Fobi and Capella were among the first to report the technique of banded gastric bypass, which by and large, is used until today.

Many bariatric surgery techniques have come and gone since then, but the banded bypass has steadily built up an experience base demonstrating its superior outcomes in terms of safety and effectiveness.

It is one of the few bariatric surgical techniques which can show more than 10 year follow up data and various randomized controlled trials are in process today.

Weight Regain after Gastric Bypass

Mali (7) demonstrated that weight regain or failure to achieve >50% EWL is associated with increased pouch and stoma sizes. Placing a ring 1-2cm proximal of the gastrojejunostomy can prevent this from happening or reverse the process in case of revision surgery.

This is the basic principle of banding the bypass: protecting the stoma against overstretching and providing restriction to the patient when overeating.

Banding the pouch also appears to have a positive effect in the prevention of weight regain.

Lemmens (9) also described in his series of 432 patients with a minimum follow up of 5 years that more than 45% of the BRYGB patients did not experience any weight loss at all vs. only 27% in the RYGB group. Of those patients who did gain weight at some point after their operation, the BRYGB patient invariably showed less regain than the RYGB patients (see fig. 1).

BMI

%

non-banded banded

Fig. 1: Less chance to regain weight for banded bypass patients (Dr. Lemmens, Obes. Surg. 2016)

“ In those rare cases of weight regain after BRYGB, the regain is also considerably less (8% of nadir weight low) compared to RYGB patients regaining weight (17-20% of nadir weight low). ”

Primary Banded Gastric Bypass

Very few randomized controlled trials are available today, but in 2015 two insightful meta analyses were published by Buchwald (6) and Mahawar (5) of 8.707 and 2.254 patients respectively.

Mahawar concludes a.o. that:

“ Banded gastric bypass is an attractive bariatric procedure with superior weight loss outcomes, best demonstrated in super-obese patients. ”

Buchwald states:

“ The current meta-analysis and trend line comparisons suggest that B-RYGB’s intermediate term weight loss outcomes may be superior to those of RYGB. Whereas RYGB and bariatric surgery patients, on the whole, reach their BMI nadir approximately 2 years post-surgery and find that their weight loss decreases, this pattern was not seen in the current analysis of B-RYGB. ”

In general it can be concluded that BRYGB improves the EWL with 15-30% within 3-5 years compared to non-banded RYGB.

Years of Follow-up

% EWL

BRGB BPD/D RYGB LAGB

Fig. 2: O’Brien et al’s systemic review and Meta-analysis of 2006 confirms Buchwald’s & Mahawars findings

Years

% EWL

banded non-banded

Fig. 3: Awad reconfirms that banded bypass produces better long term weight loss


Banded Gastric Bypass Superobese Patients

Mean

banded RYGB (n=105) non-banded RYGB (n=84)

Fig. 4: Data by Schauer, 2014

Superobese patients have a considerably higher failure rate (40-60%) than regular morbidly obese patients (20%). Magro showed that superobese banded gastric bypass had a 2 to 3 time’s lower failure rate than their non-banded counterparts. Capella, Fobi and Awad (1) had similar findings.

Schauer (4) demonstrated in 2014 in a randomized controlled trial, that banded gastric bypass is especially beneficial for the superobese patients: 20% more EWL within 2 years for the banded patients compared the standard RYGB group.


Banded Gastric Bypass Revision Procedure

In a small scale study by Bessler (3), it was demonstrated already in 2010 that patients who are regaining weight several years after their initial gastric bypass can still loose weight to a >50% EWL level after their pouch is banded.

Valk (8) et al confirmed in a larger multi center study that with at least 75% of the re-operated patients, one could achieve >50% EWL within one year after placing a ring around the dilated gastric pouch.

Months

% EWL

banded non-banded

Fig. 5: Bessler results, 2010

Complications Banded Gastric Bypass

The key concerns in performing banded gastric bypass are band related complications. The fear of erosions and even migrations derives from the initial series of banded bypass, where various materials were evaluated, like e.g. mesh and suture reinforced homemade rings with thick tied knots. Now, with prefabricated and validated rings, like the MiniMizer Ring, these concerns are not justified anymore.      

“ Overall, the band erosion and removal rates seem to be between 0 and 2% in the long term. Moreover, eroded bands are easily removed endoscopically, though surgery may be required. ”

Literature

  1. Ten Years Experience of Banded Gastric Bypass: Does It Make a Difference?
    William Awad & Alvaro Garay & Cristián Martínez, OBES SURG (2012) 22:271–278
  2. Systematic Review of Medium-Term Weight Loss after Bariatric Operations
    Paul E. O’Brien, MD, FRACS; Tracey McPhail, BSc; Timothy B. Chaston, BAppSci, PhD; John B. Dixon, MBBS, PhD, FRACGP, Obesity Surgery, 16, 1032-1040
  3. Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass—intermediate results
    Marc Bessler, M.D., Amna Daud, M.D., M.P.H., Mary F. DiGiorgi, M.P.H.,William B. Inabnet, M.D., Beth Schrope, M.D., Ph.D., Lorraine Olivero-Rivera, F.N.P.C.S.,Daniel Davis, D.O., Surgery for Obesity and Related Diseases 6 (2010) 31–35
  4. Banded Roux-en-Y gastric bypass for the treatment of morbid obesity
    Helen M. Heneghan, M.D.,Ph.D.*, Shorat Annaberdyev, M.D.,Shai Eldar, M.D., Tomasz Rogula, M.D.,Stacy Brethauer, M.D.,Philip Schauer, M.D.
  5. Primary Banded Roux-en-Y Gastric Bypass: a Systematic Review
    Kamal K Mahawar & Chirag Parikh & William R. J. Carr & Neil Jennings & Shlok Balupuri & Peter K Small
  6. Systematic Review and Meta-analysis of Medium-Term Outcomes After Banded Roux-en-Y Gastric Bypass
    H. Buchwald & J. N. Buchwald & T. W. McGlennon
  7. Influence of the Actual Diameter of the Gastric Pouch Outlet in Weight Loss After Silicon Ring Roux-en-Y Gastric Bypass: An Endoscopic Study
    Jorge Mali Jr. & Fernando Augusto Mardiros Herbella Fernandes & Antonio Carlos Valezi & Tiemi Matsuo & Mariano de Almeida Menezes
  8. Revisional Surgery for Weight Regain or Insufficient Weight Loss after Gastric Bypass using the Minimizer Ring: Short Term Results of a Multi Center Study (1.905 kb)
    Valk J.W., Gypen B., Abdelgabar A., Hendrickx L. Schijns W., Aarts E., Janssen I., Berends F. Rheinwalt K.P., Schneider S., Plamper A. Van Wagensveld B.A., De Raaff C presented at IFSO 2015
  9. Banded Gastric Bypass: Better Long-Term Results? A Cohort Study with Minimum 5-Year Follow-Up (514 kb)
    Luc Lemmens OBES SURG DOI 10.1007/s11695-016-2397-4