Banded sleeve gastrectomy (BSG) is a safe and effective procedure with acceptable rates of perioperative and band-related complications, according to a systematic review and meta-analysis comparing BSG and sleeve gastrectomy (SG). Interestingly, the authors noted that although mid- (three years) and long-term (five years) weight loss indicate that BSG is superior compared to SG, there is a higher incidence of upper GI symptoms (ie. food intolerance, vomiting and regurgitation) after BSG.
Bariatric News discussed the findings from the study, ‘Comparison of Outcomes Between Banded and Non‑banded Sleeve Gastrectomy: a Systematic Review and Meta‑analysis’, published in Obesity Surgery, with the lead author, Dr Guillermo Ponce de León (Hospital Civil de Morelia Miguel Silva, Morelia, Michoacan, Mexico).
“To our knowledge this was the first systematic review and meta-analysis that has compared the results between the two procedures. Previously, Dr Parmar and Professor Mahawar conducted a systematic review regarding BSG1, however, they did not compare the results with SG,” explained Dr Ponce de León. “The main outcome assessed in our study was weight loss at one-, three- and at five-years. We also assessed whether BSG is associated with a greater risk of complications, including reoperations, as well as the band-related complications such as band slippage, stenosis or erosions.”
They subsequently performed a systematic search to identify the relevant published studies and after review, ten articles were deemed suitable for inclusion (three randomised controlled trials (RCTs), six case–control studies and one cohort study). These studies included 1,105 patients of whom 436 underwent BSG and 669 SG, 911 participants pooled from observational studies and 194 from RCTs.
The BSG procedure was largely similar between the papers, however the authors noted that bands were placed between 4 and 6cm from the gastroesophageal junction and the diameter of the band placed varied between 6.5 and 7.5cm. In addition, several different band devices were used including the GaBP Ring Autolock non-adjustable band, Minimizer Gastric Ring Device and a home-made band which consisted of a double-layer Gortex mesh.
Outcomes
BSG showed a significantly higher %EWL at each of the analysed time points and the difference among groups was clinically relevant after the third year (p<0.005) and at five years (p<0.0001).
Regarding complications, the authors reported that there were no significant differences for leaks, postoperative bleeding, infectious complications or death. In addition, there were 25 (7.37%) reinterventions in the BSG group and 39 (6.8%) in the SG group. There were seven (one band slippage and six patients diagnosed with functional stenosis) band-related complications treated with a re-operation where the bands were either removed or the band-diameter increased to 7.5cm.
Upper GI symptoms were three times more common in the BSG group (66 patients) vs. the SG group (23 patients) and the prevalence of de novo GERD or worsening pre-existing reflux after surgery was similar between groups (BSG 15.7% vs. 11.95% SG, p=0.87).
Dr Ponce de León suggested this could be explained by the different band diameter sizes used - in both RCTs (Fink2, Gentileschi3) the band size used was 7-7.5cm compared to the three observational studies with a greater number of upper GI symptoms (Soliman4, Lemmens5, Fink6), which used a smaller band size. In a sub-analysis, the authors reported that a band size <7cm was related to a higher risk of upper GI symptoms.
In the randomised controlled trials, although the researchers used different weight loss parameters, at three-years Fink et al.2 reported an EWL of 73.9% for the BSG group vs 62.3% for the SG group, whereas Gentileschi3 reported a percentage of excess BMI loss (%EBMIL) of 103.4% and 86.29% at three years, respectively.
The difference in weight loss after the third year could possibly be related to a lower proportion of weight regain. Dr Ponce de León hypothesised: “One of the mechanisms related to weight regain after SG is the dilation of the sleeve. Therefore, the placement of a non-adjustable band will decrease this risk and, will achieve greater and sustained, weight loss.”
There were no significant differences in frequency of staple line leaks, postoperative bleeding, infections, death or reoperation between the groups in the RCTs. Furthermore, there were no significant differences regarding upper GI symptoms (regurgitation, vomiting, food intolerance, and mild to severe dysphagia). GERD data was available from one RCT with no significant difference recorded - three (6.7%) cases in the BSG group and four (8.7%) in the SG group (p=0.72).
“In terms of weight loss, we found that BSG showed greater weight loss at one-, three- and five-years with the biggest difference of weight loss noticed after the third year, being clinically and statistically significant at three and five years, respectively,” noted Dr Ponce de León. “On the other hand, we did not find differences regarding complications rates and GERD. Regarding upper GI symptoms, we found that BSG showed a greater incidence of symptoms compared to SG when retrospective studies were analysed. However, there we no differences when RCT were analysed. I want to say that we need to take with caution these results, as these are based mainly on observational and retrospective studies.”
Interestingly, the authors also assessed the results of BSG in patients with preoperative BMI>50 kg/m2, due to the fact that many authors have shown that SG could be related to poor outcomes regarding weight loss in this specific population.
“What we found, was amazing. At three years, the weight loss for the BSG ranged between 80 to 85%, whereas this was 62% for the SG. This is absolutely amazing, as the weight loss achieved for these patients was similar to patients who undergo One Anastomosis Gastric Bypass or other malabsorptive procedures,” explained Dr Ponce de León. “However, BSG is related to a lower risk for malnutrition and nutritional deficiencies. On the other hand, we should be cautious with these findings as these numbers correspond to only two observational studies.”
Future studies
He stated that the main limitation of the present meta-analysis is that almost all the included studies correspond to observational studies and there was a lack of standardisation of how the weight loss parameters were reported, the band size and the mean follow-up of the patients. In the future, he added that more RCT comparing SG and BSG are required with standardised, long-term outcomes focusing on the safety of band placement that will provide further information on whether the greater weight loss is related to food intolerance and UGI symptoms, or due to the band-enabled restriction limiting gastric pouch dilation.
“I believe that BSG should be part of the armamentarium of every bariatric surgeon. As we have shown in our paper, BSG is a safe procedure and it is related to good to excellent results,” Dr Ponce de León concluded. “The placement of the non-adjustable band will limit gastric pouch dilation, and further weight regain. For this reason, I truly believe that BSG is a good option for patients who do not have preoperative GERD and are not a candidate for another procedure.”
References
Parmar CD, Efeotor O, Ali A, Sufi P, Mahawar KK. Primary Banded Sleeve Gastrectomy: a Systematic Review. Obes Surg. 2019 Feb;29(2):698-704. doi: 10.1007/s11695-018-03626-1. PMID: 30552547.
Fink JM, Hetzenecker A, Seifert G, Runkel M, Laessle C, Fichtner-Feigl S, et al. Banded versus nonbanded sleeve gastrectomy. Ann Surg. 2020;272(5):690–5. 28.
Gentileschi P, Bianciardi E, Siragusa L, Tognoni V, Benavoli D, D’Ugo S. Banded sleeve gastrectomy improves weight loss compared to nonbanded sleeve: midterm results from a prospective randomized study. J Obes. 2020;1(2020):1–7.
Soliman AMS, Lasheen M. Efect of banded laparoscopic sleeve gastrectomy on weight loss maintenance: comparative study between banded and non-banded sleeve on weight loss. Bariatr Surg Pract Patient Care. 2015;10(3):99–104.
Lemmens L, Van Den Bossche J, Zaveri H, Surve A. Banded sleeve gastrectomy: better long-term results? A long-term cohort study until 5 years follow-up in obese and superobese patients. Obes Surg. 2018;28(9):2687–95.
Fink JM, von Pigenot A, Seifert G, Laessle C, Fichtner-Feigl S, Marjanovic G. Banded versus nonbanded sleeve gastrectomy: 5-year results of a matched-pair analysis. Surg Obes Relat Dis. 2019;15(8):1233–8.
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