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Banded bypass

The Ring: to have, or not to have?

Banding the bypass leads to increased weight loss
GABP Ring

One of the current controversies in bariatric surgery is whether to utilise a ring or ‘band’ during bypass surgery. At the recent IFSO-European Chapter meeting in Barcelona, a three-centre retrospective study comparing banded bypass (BRYGB) to conventional non-banded bypass (RYGB) was presented with four year outcomes. The study initiator PD Dr Konrad Karcz, University of Freiburg, Germany, was inspirited by talks with MAL Fobi who encouraged him to perform this study.

“Writing in the journal Obesity Surgery, the father of the Roux-en-Y gastric Bypass, Dr Edward Mason, wrote ‘Roux-en-Y Gastric Bypass is primarily a restriction operation, just as with VBG, it is important that the outlet of the pouch does not stretch’”, began Karcz. “This loss of the restrictive component of the operation was confirmed by increased caloric intake in some patients.”

The Silastic Ring Gastric Bypass (SRGBP) was introduced by Mal Fobi in 1989, in an effort to enhance the restrictive mechanism of the Roux-en-Y gastric bypass by controlling the stoma size and reducing the reservoir capacity after the gastric bypass. Stretching of the outlet combines the pouch and the dilated proximal jejunum into a big reservoir.

Over the years, numerous materials and implants have been used to ‘band’ the bypass including marlex mesh, porcine graft, bovine graft, Ethibond suture  the LapBand and mostly the GaBP Ring. “However, opinion is divided as to whether BRYGB or RYGB produces the better long-term results,” he added. “Therefore, we decided to retrospectively examine the results from three centres.”

Study

The aim of the retrospective study was to evaluate whether BRYGB procedures resulted in better postoperative weight loss and significantly improved long-term weight loss compared with RYGB. Between 2007 and 2011, 236 patients in the banded group had a conventional laparoscopic Roux-en-Y gastric bypass with additional restrictive silastic ring (The GaBP Ring, Figure 1) and 349 in the non-banded group had a conventional laparoscopic Roux-en-Y gastric bypass alone.

All the patients were operated in three Bariatric Centres of Excellence in Sint Niklaas (Belgium) under Luc Lemmens’ ledership, in Freiburg by Konrad Karcz and in Jeddah (Saudi Arabia) under Waleed Bukhari’s leadership.

Figure 1: Implanted GaBP Ring

The primary outcome was post-operative reduction of BMI and excess weight loss (EWL, %) at three-, six- and 12 months, two, three and four years. Baseline patient demographics between the banded and non-banded groups respectively were similar in terms of mean weight (122kg vs. 115kg), mean BMI (42 vs. 41) and mean excess weight (62kg vs. 57kg).

The outcomes for BMI at four year show that patients in the conventional group had a lower mean BMI than the banded patients from the date of the operation to two years. However at three years, the mean BMI was the same in both groups and at four years the mean BMI was lower in the banded group (Table 1).

 

Day1

3mo

6mo

1   year

2   year

3   year

 4 year

Banded

43

34

31

28

27

26

25

Non-banded

41

33

29

27

26

26

27

Table 1: Post-operative data mean BMI

The authors reported a similar pattern when examining the post-operative mean EWL (%) with a benefit in conventional group out to six months but with the benefit then shifting to the banded group out to four years (Figure 2 and Table 2). Both these outcomes are particularly important as the baseline mean weight (122kg vs. 115kg), mean BMI (42 vs. 41) and mean excess weight (62kg vs. 57kg) were higher in the banded group.

 

3mo

6mo

1 year

2 years

3 years

 4 years

Banded

40%

58%

73%

77%

79%

85%

Non-banded

40%

60%

72%

74%

72%

69%

Table 2: Post-operative data mean EWL (%)

Figure 2: Post-operative data mean EWL (%)

Complications

The authors also examined ring-related complications and noted three patients where the Ring was open two years after operation, leading to wait gain. There were no erosions reported in this series.

However, Stubbs et al. and Fobi et al. have reported instances of band erosion (rate of 1.63%, 48 of 2,949 patients) or migration into the gastric lumen after banded gastric bypass, although the erosion incidence was lower (0.92%) in primary operations.

Removal of the ring is combined with significant weight gain occurring in 43.75% patients who underwent ring removal, with an average of 14% EWL regained (Fobi et al. 2011 IFSO Congress and Barroso et al. 2007 IFSO Congress).

Conclusion

The data suggests that banding the bypass leads to better weight loss after four years and helps reduce the weight regain, which may be due to prevention of Pouch-outlet dilation, the authors concluded. In addition, the GaBP-Ring is a standardized device which is easy to remove in case of complications.

GABY study

The two years results of the multicentre, prospective, randomized Banded versus conventional laparoscopic roux-en-y study, designed to compare banded and non-band laparoscopic Roux-en-Y gastric bypass, will be presented at the IFSO World Congress in New Delhi, India, in September 2012.

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