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Weight gain, hypoglycaemia and the banded-bypass

It is important to understand the mechanisms of a banded bypass and many people are under the misapprehension that the goal of a banded bypass is to make people lose more weight
Hyperglycaemia can be treated by pouch downsizing or placing a ring around the pouch.
The MiniMizer Ring with a gastric bypass is a valid procedure that belongs in the armamentarium the bariatric and metabolic surgeon

Dr Rudolf Steffen is a bariatric and metabolic surgeon at the Hirslanden Klinik Beau-Site in Bern, Switzerland, one of the leading centres in the country for bariatric and metabolic surgery. Since 2003, he has performed more than 3,000 banded bypass operations and has recently utilised the MiniMizer Ring (Bariatric Solutions) as part of his procedure. Bariatric News talked to Professor Steffen to discuss the reasons why patients experience weight regain, the benefits of the banded-bypass and the advantages of the MiniMizer Ring.

“The reasons why patients experience weight regain two years after a gastric bypass is because it is a restrictive operation and if the restriction fails, the patients regain weight,” began Professor Steffen. “In our experience, 29% of 404 patients in the fourth year after unbanded bypass required a pouch revision with a Fobi-ring for weight regain because of loss of restriction. Percentages increasing thereafter.”

Dr Rudolf Steffen

As a result, he recommends banded bypass to all his bypass patients who are suitable for the procedure, after explaining the advantages and disadvantages of the procedure and he informs them that in his opinion, there is good, but limited data. He also recommends a banded bypass for revision procedures, primarily for those patients who received a gastric band in the mid 90’s.

“I explain that approximately 50% of patients will probably not need one but there is no way to know who these patients are,” he added. “In addition, I tell them that about half of all bypass patients will need a reoperation due to a loss of restriction. It is important to give our patients as much information as possible so they can make an informed decision. Some patients may not like the idea of having a foreign body inside them, so they just have a bypass.”

He said that he does not perform many sleeve gastrectomies (20 or so a year), as he do not want a restriction in the same location where a leak might occur and explained that he views the sleeve as a high-resistance tube, so in the first instance it does not require a band.

“However, a banded sleeve can be considered in a secondary case, but in such cases I usually convert the sleeve to a bypass.”

Professor Steffen said that it is important to understand the mechanisms of a banded bypass and many people are under the misapprehension that the goal of a banded bypass is to make people lose more weight. He clarified this by stating that the goal of the banded bypass is not to regain weight, which has been demonstrated in several multi-centres studies that showed after two or three years, the non-banded patients reported more weight regain.

Benefits of the banded bypass

According to Professor Steffen, one of the key elements of the banded bypass procedure is its ability to help protect the anastomosis and the jejunum against overstretching. He stated that the way the band is placed – but he prefers the name ring as it should be ‘thin’ – impacts on its effectiveness. He places the MiniMizer Ring approximately 1.5–2cm above the anastomosis in a peri-gastric technique. This allows the surgeon to achieve two goals; first, pouch dilatation is prevented, and second, by using the peri-gastric technique the ring is fixed in place so it cannot slip in either direction.

“I understand that most surgeons put the Mini- Mizer Ring close to the anastomosis and then fix it with sutures,” he explained. “I have experience of other rings slipping downwards over the alimentary limb causing complications. My suggestion is to go further up by the omentum minus and make a small tunnel peri-gastrically and place the ring there. Perhaps 1–1.5cm above the anastomosis and it cannot slip anymore, it cannot go up and it cannot go down. This also means a surgeon does not require sutures because it is being held by the omentum.” He also said that a banded bypass helps to minimise dumping syndrome, as one of the worse complications that can happen after gastric bypass is hyperglycaemia, adding that his group has reported it in a paper.

“Hyperglycaemia can be treated by pouch downsizing or placing a ring around the pouch. We have published this to be successful in 10 out if 11 patients,” said Professor Steffen. “What we see approximately 18 months after a gastric bypass procedure is that every anastomosis, even the ones that were stenotic at the beginning, become enlarged and too wide. In these patients, carbohydrate-rich food goes straight down through the oesophagus and into the jejunum, and the carbohydrates cause a sharp increase in glucose, insulin and GLP-1. As a consequence of these increases, there is a rapid decrease in the glucose and even before it becomes pathologic hyperglycaemic the patients feel symptoms of hypoglycaemia because of the sharp fall in blood glucose. When I place a ring, I use a minimum diameter that is 1mm larger than the pouch so it is never attached to the pouch. In my opinion it only becomes important after 12–18 months.”

MiniMizer Ring

With regards to the MiniMizer Ring, he explained that the Ring is very easy to place and has several positions where a surgeon can lock the device depending on the diameter required, and the Ring can even be re-opened it if required. In addition, when a foreign body is placed into the gastrointestinal tract, some of them will eventually erode into the lumen and so he wants a device that can be easily removed endoscopically if necessary. He said the MiniMizer Ring was ideal because it is small, soft and has smooth edges, it can be removed with ease. He also said the MiniMizer Ring comes in sufficient sizes, although cautioned that it is not necessary to go below 6.5mm in primary cases, and if a surgeon goes to 6mm or 5.5mm they may see the incidence of food intolerance rise sharply. “A key point on the design of rings is that they should be thin and small. I have used a ring before that was 8mm, but because I make small pouches, this implant caused dysphagia in too many cases. But the MiniMizer Ring is perfect for the size of my pouches.”

He added that there are a few contra-indications to banded bypass, primarily when a surgeon has to perform a posterior repair of a hiatal hernia, as he does not want to add further restriction and it is not necessary in the majority of patients. In addition, if there is a recurrence of the hernia and a surgeon has to remove a ring, it is a very difficult procedure. The only other relative contra-indication is in patients aged 70 or older.

“If a bariatric surgeon chooses not to place a ring, in my opinion, it is justified because we do not have the long-term data yet from prospective, randomised clinical trials,” he concluded. “However, in my experience it is of benefit to explain the procedure to gastric bypass patients. The ring can always be placed in a revision procedure if the patients has weight regain or present with hyperglycaemia. For me, the MiniMizer Ring with a gastric bypass is a valid procedure that belongs in the armamentarium the bariatric and metabolic surgeon.”

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