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Preventing weight regain and the banded bypass
Although the Roux-en Y gastric laparoscopic bypass is associated with long-term weight loss, some patients will regain weight due to an enlarged pouch and/or stoma . In an interview with Bariatric News, Dr Jan Willem Greve from the Zuyderland Medical Center Heerlen and Dutch Obesity Clinic South, The Netherlands, discusses the reasons why patients experience weight regain, the advantages of a banded bypass and the benefits of using the MiniMizer Ring (Bariatric Solutions).
“I am quite sure that in a number of patients the weight regain is a result of losing the restriction,” began Dr Greve. “There are many people now who say that we should not talk about malabsorption or restriction because they believe that the changes are more physiological, such as gut hormones and metabolic changes. But I see quite a number of bypass patients who gain weight who present with an enlarged pouch and/or stoma and when you bring back the restriction, they lose weight. Therefore, we recommend the banded bypass procedure for all our patients.”
All primary patients have the banded bypass procedure explained to them – the advantages and risks. He said that some patients decide that they do not want a foreign body inside them, others decide against the procedure because of the risk of dysphagia, but patients declining a banded bypass is very uncommon.
Dr Greve first performed the banded bypass because of the outcomes reported by Dr Mal Fobi that clearly showed that the banded bypass does prevent weight regain. He added that from his own experience, patients do return to the clinic with weight regain, because of a loss of restriction after a regular bypass
“Again people say don’t talk about restriction, talk about malabsorption. But in my view, the bypass is a predominantly restrictive procedure with the added element of patients losing their feelings of hunger,” explained Dr Greve. “From my own series, all patients benefit from the banded bypass whether they are obese or super-obese.”
“I have also had two, maybe three patients who have presented with extreme weight loss (BMI<20). We performed endoscopy, x-ray and everything looked perfect and when we removed the band they stabilised or regained a little weight. We don’t know if there was a functional stenosis, but the patient’s BMI remained in the low 20s and the removal of the band made them able to eat again.”
Dr Greve has been using the MiniMizer Ring for about eight months, prior to using the Ring his centre used an in-house silicone grade tube that has demonstrated to be safe and effective in preventing weight regain with good outcomes reported in the literature (Schauer, P. et al. Banded Roux-en-Ygastric bypass for the treatment of morbid obesity. SOARD (2103)). His centre has offered banded bypass as a primary procedure since about 2010 performing more than 800 banded bypass procedures.
However, in The Netherlands there have been some concerns about the use of prosthesis in patients following issues with vaginal meshes and in turn, this resulted in a debate about which devices could be used. In the end, it was decided that only officially approved, registered devices could be used in patients. As a result, his centre opted to use the MiniMizer Ring.
Greve described how the MiniMizer Ring has features that help facilitate the ease of the procedure, in particular the ease at which the operator can adjust the size of the Ring to suit the patient. In general, his centre use a standard 6.5mm for females and 7.0mm for males, although in some patients they increase the size to 7.5mm or even 8.0mm, which is simple to do with the MiniMizer Ring.
He remarked that the MiniMizer Ring is not placed to cause immediate restriction, it is there to prevent dilatation, so the Ring should not be too tight. Although there are many different ways to create an anastomosis, he added that the size of the anastomosis is not important in a banded but the length of the pouch is, because the surgeon must place the Ring at 1-2cm above the anastomosis to avoid strictures and erosions.
He again emphasised that when surgeons are performing a banded bypass, they should be careful not to create a short pouch because if they do, by definition they are placing the Ring on the gastric anastomosis. It is important to prevent the Ring being in contact with the small bowel. He also fixes the Ring with a non-absorbable, mono-filament suture, which has a decreased risk of bacterial infection compared to multi-fibre suture.
In total, he said his centre has performed about 200 banded bypasses using the MiniMizer Ring and as with all new devices, there is a learning curve to overcome any technical issues.
“We used a different technique with the Goldfinger before and the MiniMizer Ring has a hard, flexible tip which we use to push through the mesentery of the pouch. So far, we have had at least one Ring erosion, which was due to the learning curve,” he explained. “When pushing the tip through the meso, the operator must use caution not to make a lesion of the pouch.”
Nevertheless, he said banding the bypass is a quick procedure and only adds an additional 5-10 minutes to the procedure time.
“I am part of the Dutch Obesity Clinic with ten clinics in total. Of these clinics, we are the only group implanting the Ring. We expected that the Ring would prevent weight regain two, three, four years later,” he said. “However, after looking at our results, to our surprise we saw that weight loss percentage within the first two years was greater compared to non-banded bypass, compared to the non-banding centres in our group. This is despite implanting the Ring in a non-restrictive way and placed loosely around the pouch.”
The exact same outcome occurred in the ‘Banded Versus Conventional Laparoscopic Roux-en-Y Gastric Bypass (GABY)’ clinical trial, which compared weight loss in non-banded and banded bypass patients. Dr Greve added that the outcomes from his centres were interesting as the benefit of the banded bypass was been confirmed in a different ‘real world’ clinical setting across several sites
At his clinic, they offer the whole range of bariatric procedures, including adjustable gastric bands and particularly for low BMI patients who do not want the risk of malabsorption. He said that the gastric bypass is not a procedure that offers patients calorie malabsorption, but there is some vitamin, mineral and calcium malabsorption. So for a patient who is willing to stick to the rules, the adjustable gastric band is a good treatment option and he added that he still has patients from 10-15 years ago who have maintained their weight loss and do not want to get rid of their band.
Adjustable banded bypass
“I do not believe that you should combine true restriction with true malabsorption – because then you have a very risky patient - an important and very true statement of Professor Nicola Scopinaro. So I stopped doing the elongation of the limb (going distal) as a revision procedure and started banding the bypass with an adjustable band. Because you do not know the exact size required and the adjustable band allows modification of the size. There are some interesting endoscopic techniques that allow you to reduce the size of the pouch or stoma, but I believe there are still some question marks over their durability,” said Dr Greve. “Since we have been performing the banded bypass, we are performing fewer revisions. However, if a patient does present with regain I favour banding the bypass with an adjustable gastric band because the exact amount of restriction this particular patient requires is unknown and the adjustable gastric band allows me to change the restriction overtime.”
He said that a few years ago he performed a number of primary banded bypass procedures with the adjustable gastric band as part of a feasibility study with good results. However, as well as the additional costs involved there was also the increased risk of erosion and slippage. Therefore, he uses the MiniMizer Ring for primary procedures and the adjustable gastric band for revision procedures only.
“For me, the gastric bypass remains the gold standard but there is no one procedure that will be able to treat every patient for the rest of their lives,” he concluded.