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Banding the bypass - a redo procedure

A band provides external reinforcement to help prevent recurrent dilatation of the gastric pouch, as well as better long-term control of the rate of emptying of the pouch and caloric intake

Performing a banded bypass as a primary procedure has grown in popularity as surgeons loom for ways to prevent weight regain in patients. However, the banded bypass is also performed as a redo procedure in many centres. Bariatric News talks to Dr Jody Valk, Department of General Surgery, ZNA Stuivenberg Hospital, Antwerp, Belgium, who discusses why his centre utilise a band to help patients loose regained weight.

In his centre, they perform approximately 800 gastric bypass patients each year and around 10%? fail to achieve sufficient weight loss or experience weight regain. In addition, they also get the same number of patients via referrals from other hospitals.

“Although this appears to be a small number of patients, I think there is very little focus on redo procedures in the media, so many patients do not realise that there are options if they have weight regain,” said Valk. “Unfortunately, it is often quite two or three years before the patient realises they are gaining weight and may need a redo procedure.”

As well as non-compliance by patients of their post-operative regime (exercise, diet etc), there are several causes of weight regain including gastro-jejunostomy dilatation, gastro-gastric fistula, inadequate length of the alimentary limb and pouch dilatation. He said that in the majority of referral cases, pouch enlargement is the most common cause for weight regain with some patients presenting with a pouch that is double the size it was after their initial bypass procedure.

Dr Jody Valk

“What we do not know is whether this is a technical failure - perhaps because the operation was performed by a less experienced surgeon - or because the patient is over-eating. What we do know if that these patients can eat two sometimes three times as much as a normal bypass patient,” he added.

Valk explained that in his centre they only perform a banded bypass as a redo procedure, not as a primary procedure.

“We operate a ‘wait and see’ policy, as we do not see a sufficient number of patients reporting weight regain to justify adopting a banded bypass as a primary procedure for all patients,” he said. “The cost of the band is not reimbursed by health insurance for a primary procedure, only for a redo procedure. In Belgium the government will only reimburse patients for the cost of a band/ring if they have weight regain up to BMI35, otherwise the patients have to pay for it themselves. We think it is better to see how successful the initial bypass is and if the patient has weight regain, they can get the cost of the band reimbursed by the government. The procedure is performed in a day clinic so there are no additional costs for hospital stay.”

Banded bypass

Before his centre adopted a policy of banding bypass as a redo procedure, they used to resize the pouch or create a new gastroenterostomy. However, despite having a few successes they soon decided that these methods were not achieving satisfactory results so they opted to defend the increase in the pouch by using a band as a restrictive element.

Valk explained that a band provides external reinforcement to help prevent recurrent dilatation of the gastric pouch, as well as better long-term control of the rate of emptying of the pouch and caloric intake.

In addition, he said that as a redo procedure the band has several advantages over other revisional approaches in that it is safer and technically simpler with a reduced risk of leaks, stenosis (since no transection or new anastomosis) and fewer malabsorption complications (no change in absorption).

“We saw within the first few cases that our patients responded well to the band and so that’s when we changed protocol to the banded bypass for redo procedures,” said Valk. “We first started to use the Fobi Ring (Bariatec Corp), but we had instances of mechanical failure (band breakages), so we switched to the BypassBand (Surgtech) but had a few erosions, so then we opted for the MiniMizer Ring (Bariatric Solutions). The MiniMizer Ring has a round surface so has minimal contact with the stomach surface and so far we have not had any technical problems, no erosion, no migrations and no failures.”

Surgical technique

When placing a ring, Valk creates a small pouch with a 36f bougie and where possible, a smaller gastroenterostomy but that is in the minority of cases. After they have downsized the pouch, they place the MiniMizer Ring around the pouch and use the bougie to calibrate the size accordingly. He explained that the MiniMizer Ring allows them to adjust the size according to the patient, this is usually 6.5-7cm for women and 7-7.5cm for men.

“Our results have been very good with approximately 75% of patients reporting additional weight loss after having a MiniMizer Ring, and more importantly they did not gain weight,” he added. “It is a quite an easy procedure to perform and the Minimizer Ring with an appropriate availability of sizes allowing quick and simple to placement.

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