Researchers from The Netherlands have reported that banded Roux-en-Y gastric bypass (RYGB) has significantly higher weight loss versus non-banded RYGB, especially in the long term. The findings from the multi-centre study also found that increased weight loss of the banded intervention did not result in a difference in improvement or remission of comorbidities between the two groups. The outcomes, reported in the paper, ‘The Benefits of Banded over Non‑banded Roux‑en‑Y Gastric Bypass in Patients with Morbid Obesity: a Multi‑center Study’, were published in Obesity Surgery.
“There are several reasons for weight regain after Bariatric Surgery. An important cause of weight regain after Roux-en-Y Gastric bypass is pouch dilatation or dilatation of the gastro-jejunostomy,” explained PhD candidate and first author of the study, Marijn Jense (Zuyderland Medical Center, the Dutch Obesity Clinic South, Heerlen, and Maastricht University Medical Center, Maastricht). “Dilatation of the pouch or gastro-jejunostomy can be caused by bad eating habits such as eating large volumes, eating too fast or not chewing adequately.”
Previous studies have demonstrated that placing a band or silicone ring above the gastrojejunostomy can improve the amount of excess weight loss (EWL) by 15 to 20% up to nine years post-surgery. However, the particular function of the ring is yet to be determined.
“The exact function of using a ring in a banded Roux-en-Y gastric bypass is not yet known. The effect is probably more intricate than pure restriction as the ring is loosely placed around the newly created pouch - in contrast with a gastric band,” added co-author, Dr Evert-Jan Boerma (Zuyderland Medical Center and the Dutch Obesity Clinic South, Heerlen). “Once a portion of food enters the stomach the pouch cannot expand bigger than the diameter of the ring and will therefor result in additional tension on the gastric wall and offer additional satiety. Furthermore, it will force patients to adapt better eating habits, such as eat slowly and chew food sufficiently, as large chunks of food will not pass the ring without problems. And off course, a ring will prevent mechanical tension on the pouch and gastro-jejunostomy and in that way prevent dilatation on the long term.”
Study design
This retrospective study was designed to evaluate the effect of a banded RYGB compared to a non-banded RYGB on long-term weight loss results and improvement or remission of comorbidities. At the time of the study, the researchers created a ring by using a medical grade ventriculoperitoneal drain, which was approved in hydrocephalus management and was therefore approved for long-term implantation. The tube size was standardised depending on gender. For females patients a ring of 6.5cm was used and for male patients a ring of 7.0cm.
All patients who underwent a primary laparoscopic RYGB between July 2013 and December 2014 in two locations of the Dutch Obesity Clinic (DOC) were included. Patients were excluded if they received a RYGB as conversional surgery, received an adjustable band or if they followed an individual treatment instead of the standard group treatment at the DOC. Comorbidities (type 2 diabetes, hypertension, Obstructive Sleep Apnea Syndrome (OSAS), dyslipidaemia) and Quality of Life) were assessed during screening and follow-up up to five years. The study included 375 patients: 184 patients underwent non-banded RYGB (49.1% - 147 female patients, 79.9%, mean age 43 years (± 10) and a mean preoperative BMI of 44.7 kg/m2 (± 5.5)) and 191 patients underwent banded-RYGB (50.9% - 136 female patients, 71.2%, mean age 43 years (±11) and a mean preoperative BMI of 44.3 kg/m2 (±5.9). The researchers reported no significant differences in comorbidities at baseline except for a higher prevalence of OSAS in the banded group (p<0.001).
Outcomes
At five-years, a total of 79 patients (20.5% - 49 from the non-banded and 30 from the banded group) were lost to follow-up. At all follow-up time points, the percentage of total weight loss (TWL) was significantly higher in the banded group vs. the non-banded group. For the non-banded group, the mean percentage TWL was 16.0, 30.4, 31.4, 28.6, 27.4, and 27.6 at three-months and yearly out to five years, respectively. For the banded group, the mean %TWL was 20.5, 35.6, 35.6, 34.0, 31.0 and 32.6 for three-months and annually out to five years, respectively. The mean difference was 5.0% TWL at five years post-surgery (p<0.001). At all follow-up points, except at four years post-operative, the differences in excess weight loss (EWL) were statistically significant in favour of the banded RYGB.
With regards to comorbidities, during screening and at five years follow-up, there were no significant differences between the two study groups in either improvement or complete disease remission of hypertension, diabetes mellitus, OSAS and dyslipidaemia.
The complication rates did not significantly differ between the two study groups (p=0.20). Twenty-three patients had complications, eight from the non-banded group (seven received reinterventions; six laparoscopically and one endoscopically) and 15 from the banded group (seven patients (4.3%) had their ring removed because of complaints and two patients (1.2%) underwent a silicone ring replacement operation. There were no instances of band erosion.
Pre-operatively Quality of Life RAND-36 score in the non-banded group had a mean score of 66.5 for mental health and 54.6 for physical health. At five years, the mean score was 69.2 for mental health and 69.4 for physical health. In the banded group, the pre-operative mean score was 67.0 for mental health and 48.8 for physical health. At five years, the mean score was 66.7 for mental health and 70.3 for physical health. There were no significant differences between the two study groups at either time point.
“At that time the of the study, the MiniMizer Ring (Bariatric Solutions) was not yet available to us. At present, we use the Minimizer ring in all our primary banded Roux-en-Y cases. In my experience, the MiniMizer Ring can easily be placed around every pouch because of the several closing positions. Besides the easy placement, removal (if needed) is also a quick and relatively easy procedure. Fixation can easily be done by placing two sutures through the loops at the end of the MiniMizer,” said Dr Boerma. “One of the most important things to remember when placing a MiniMizer Ring is to place it loosely around the pouch. Our rule of thumb is to place the ring around the pouch with the orogastric tube in place and enough room for a 5mm grasper to easily fit between the pouch and the ring. In addition, it should be placed at least 2cm above the gastro-jejunostomy and at least 2cm below the gastro-esophageal junction. Placement can be performed from both the medial and the lateral side of the pouch.”
Moreover, according to the researchers the banded-RYGB procedure can be performed in the vast majority of bariatric patients.
“The current literature does not describe any contraindications for the banded bypass procedure. This is in accordance with our own experience, since we have no specific patient group for which the banded bypass would not be an option. Except of course for the patients in who a bypass in general is not applicable,” added Jense. “We do think banded procedures are useful in all patient groups eligible for surgery and we do not see a difference on effect in any specific patient group.”
“In our opinion the banded bypass is an essential option in the armamentarium of the bariatric and metabolic surgeon to obtain a successful long-term result in the majority of bariatric patients,” the researcher concluded. “Based on these study results, we recommend performing a banded over a non-banded Roux-en-Y gastric bypass.”
Further information
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