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, slowing down the passage of food and providing restriction to the patient when overeating.
Banding the pouch has 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).
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 Doing it right the first time!
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. ”
“ 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.”
More recently Galal stated in his single center retrospective analysis of 142 patients that banded gastric bypass has good results in terms of weight loss and weight loss maintenance in both primary and conversional bariatric procedures with acceptable incidence of band-related complications.
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.
Fig. 2: O’Brien et al’s systemic review and Meta-analysis of 2006 confirms Buchwald’s & Mahawars findings
Fig. 3: Awad reconfirms that banded bypass produces better long-term weight loss
Banded Gastric Bypass Superobese Patients
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 times lower failure rate than their non-banded counterparts. 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 to the standard RYGB group.
Banded Gastric Bypass and prevention of Dumping Syndrome
Fig. 5: Dumping Syndrome
Several theories support the fact that the Banded Gastric Bypass can potentially aid against a common complication, namely Dumping Syndrome. By slowing down the passage of food, caused by the MiniMIZER Gastric Ring, patients suffer less from this complication.
Linke (11) displayed limited extra weight loss but did show the positive effect the Banded Bypass has on Dumping Syndrome after revisional surgery with the MiniMIZER Gastric Ring.
Dr. Buchwald in his meta-analysis stated a significant proportion of RYGB patients experience dumping syndrome, whereas no instances of the syndrome were reported in B-RYGB patients in the included studies.
Banded Gastric Bypass as a 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.
Boerboom (10) showed in 2019 that in 75% of patients with weight regain after RYGB, further weight regain was prevented and 26% of patients started to lose weight again.
A significant outcome of this study was the difference in results for Good – and Poor responders.
Patients that have not achieved an EWL% of 50 or higher after a Bariatric Procedure are Poor responders, whereas those that have achieved an EWL% of 50 or higher are classified as Good responders.
Adding a MiniMIZER Gastric Ring to a Gastric Bypass will result in renewed significant weight loss for Good responders, where this is not the case for Poor responders. See figure 5.
Fig. 6: Boerboom
Complications Banded Gastric Bypass
The key concerns in performing banded gastric bypass are ring 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 no longer 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. ”
Several results have been published related to Banded Bariatric Procedures and its potential complications. Dr. MAL Fobi (14) published a retrospective study of his 2.949 banded RYGB patients and found ring erosion in only 0,92% of his primary patients. Additional Dr. Galal (15)
“In 142 patients mentioned the following: band-related complications after 5 years: three erosion and five patients complained of persistent dysphagia. One band needed reposition. Perioperative surgical complications: two bleeding, one leakage, one port-site hernia, and one food impaction.” And Dr. Lemmens (9) “In the following years, more banded patients than non-banded patients feel some late dysphagia, sometimes even with vomiting when they eat too fast.”
To prevent the risk of ring removal due to dysphagia or regurgitation, surgeons should take notice not to place the ring too tight around the gastric pouch during surgery.
The MiniMIZER Gastric Ring related complication rate in surgeries is acceptably low and therefore should not be a barrier to withhold patients of the outstanding results that can be achieved in Banded Bariatric Procedures.
Outcome of revisional bariatric surgery for insufficient weight loss after laparoscopic Roux-en-Y gastric bypass: an observational study
Katja Linke, M.D.a, Romano Schneider, M.D.a, Martina Gebhart, M.D.b, Truc Ngo, M.D.b, Marc Slawik, M.D.b, Thomas Peters, M.D.b, Ralph Peterli, M.D.a,*
Long-term weightlossoutcomesafterbandedRoux-en-Ygastricbypass: a prospective10-yearfollow-upstudy
Daniéla Oliveira Magro, C.N.,Ph.D.a,b, Mirian Ueno,C.N.,Ph.D.a, João deSouza Coelho-Neto,M.D.,Ph.Da,b, Francisco Callejas-Neto,M.Sc.,M.D.a,b, José Carlos Pareja,M.D.,Ph.D.a,b, Everton Cazzo,M.D.,Ph.D.a,b,*
Band Erosion: Incidence, Etiology, Management and Outcome after Banded Vertical Gastric Bypass
Mal Fobi, MD; Hoil Lee, MD; Daniel Igwe, MD; Basil Felahy, MD; Elaine James, MD; Malgorzata Stanczyk, MD; Nicole Fobi, MD, Obesity Surgery, 11, pp-pp, Band Erosion: Incidence, Etiology, Management and Outcome after Banded Vertical Gastric Bypass
Impact of Laparoscopic Banded Gastric Bypass on Weight Loss Surgery Outcomes: 5 Years’ Experience
Abdelrahman Mohammad Galal1,2,3,4 & Evert-Jan Boerma1,2 & Sofie Fransen1,2 & Berry Meesters1,2 & Steven Olde-Damink3 & Magdy Khalil Abdelmageed4 & Alaa Abass Sabry5 & Alaaeldin Hassan M. Elsuity4 & Jan Willem Greve1,2,3