Roux-en Y gastric laparoscopic bypass is associated with longterm weight loss, as well as reducing the rates of diabetes remission and lowering the risk of cardiovascular and other health outcomes1. Nevertheless, in some patients, the bypass will fail leading to patients regain weight.
Bariatric surgeons attempted to provide an extra restriction to the bypass by placing a ring at the gastroenterostomy with mixed results. In 1998, MAL Fobi developed a refined technique for banding the bypass as a primary operation, with the ring placed above the gastroenterostomy2. Banded bypass and banded sleeve gastrectomies are now regularly used to protect against pouch dilatation protect the anastomosis and the jejunum against overstretching, minimising dumping syndrome and stabilising long term weight loss.
The most recent results from a multi-centre clinical trials comparing non-banded and banded bypass demonstrated that banded patients achieved a mean excess weight loss of 90.01%, compared with 72.94% patients in the non-banded group3.
Bariatric News spoke to Dr Luc Lemmens, Meerdonk, Belgium, about his experience with the MiniMizer Ring (Bariatric Solutions), the advantages of the device and why he advises all his patients to receive a banded bypass. .
“When I first started bariatric surgery I used to perform biliopancreatic diversion and about ten years ago I performed my first bypass,” said Lemmens. “After a few years and about 250 bypasses, we noticed patients were starting to regain weight. The patients told us that they had no restriction any more, and they were afraid of regaining weight.” Around this time, he saw a presentation by MAL Fobi who described a method of employing a ring with a bypass. Lemmens immediately thought that it was a good idea to utilise a ring to provide more restriction to the bypass
“The banded bypass does not prevent the pouch from dilatation, but it does secure a fixed stoma size,” says Lemmens. “We hope it will prevent dilatation of the first jejunum loop because this loop will become the neo-stomach after dilatation.”
The procedure also minimises dumping syndrome by preventing rapid emptying of the pouch into the jejunum. By controlling the eating behaviour of the patient due to the fixed outlet and preventing the dilatation of the jejunum, it can also stabilise long term weight loss.
“We noticed that patients who had a banded bypass were not regaining weight and have only had to re-operate because of weight regain on patients who only had a bypass,” he says.
Lemmens implanted this first MiniMizer Ring in November 2012 and has implanted approximately 50 rings since. He claims the MiniMizer Ring has several significant advantages including the ease of placement and closure, and the intra-operative flexibility allowing adjustments to the desired diameter.
The Ring can be tailored to suit several closing positions from the largest to the smallest ring size: from 8.0 cm length (approx. 26mm internal diameter), to 7.5 cm length (approx. 24mm internal diameter, 7.0 cm length (approx. 22mm internal diameter) and 6.5 cm length (approx. 20mm internal diameter). Lemmens said this enables the operator to address individual patients’ requirements, as well as revision cases.
“The MiniMizer Ring is very easy to place and a key advantage is the ease at which one can close the ring,” says Lemmens. “Another significant advantage is that one can enlarge the ring. Recently, we had one case where the patients could not eat with the 6.5cm, so in the space of a few minutes we were able to enlarge the ring. This is important because all patients are different. Another patient could not manage with the restriction so we opened the band completely. If the patient starts to gain weight, we can re-close the band again.”
He explained that the ease of placing the MiniMizer Ring is assisted by a blunt, silicone covered introduction needle that simplifies retrogastric placement. Specifically, he added that the needle is useful in very obese patients and in laparoscopic sleeve gastrectomy procedures as this enables the operator to get behind the pouch.
In order to reduce the risk and avoiding damage to the posterior wall of the stomach, Lemmens advises operators to leave the big naso-gastric tube inside the pouch before passing behind the pouch.
“In my own case series of 600 cases I have not had to re-operate on any patients who had a banded bypass due to the patient regaining weight,” says Lemmens. “Now we advise all our bypass patients to have banded bypass as this offers the best solution for most patients."
1. Adams et al. Health benefits of gastric bypass surgery after 6 years.JAMA. 2012;308:1122-1131.
2. Fobi M.A., Lee H., Holness R., Cabinda D., Gastric bypass operation for obesity. World J Surg. 22:925-935 (1998).
3. Presented at IFSO 2012 and to be published in April 2013.