Laparoscopic banded sleeve gastrectomy (LBSG) appears to be significantly more effective than laparoscopic sleeve gastrectomy (LSG) in terms of weight loss in the midterm follow-up, according to researchers from Italy. The randomised study, ‘Banded Sleeve Gastrectomy Improves Weight Loss Compared to Nonbanded Sleeve: Midterm Results from a Prospective Randomized Study’, published in the Journal of Obesity, sought to compare LBSG and LSG over a four-year follow-up.
The researchers noted that the literature demonstrates weight loss flattening out and initial weight regain starting from two years after surgery. However, redoing surgery after LSG is a challenge and the rate of recurrence and inadequate weigh loss is significant.
There is growing evidence that banded bypass – placing a ring at the gastric pouch during a gastric bypass to prevent gastric dilatation – can prevent weight regain and eventually improve the weight loss maintenance. The authors noted that ring related weight loss is a mix of malabsorptive and restrictive mechanism including reduced food intake, effect on endoluminal pressure and oesophageal peristalsis, hormonal effect and altered gastric emptying. The main benefit of the ring should start in the mid- and long-term from surgery, when the dilatation of the gastric pouch is responsible of the weight regain.
Therefore, the researchers assessed whether placing an adjustable ring around the sleeve pouch just below the gastroesophageal junction, would have the same impact on weight regain. The ring used was the GaBP Ring Autolock System, a radiopaque silicon-coated implantable device with a plastic one-way lock mechanism at the ends of the ring. It was placed 4cm distal from the cardia hiatus through a retrogastric tunnel created in the pars flaccida of the hepatogastric ligament. The diameter of the ring selected to be used in this study was 7cm; only two patients received a 7.5 cm ring due to excessive narrowing of the gastric tube. To prevent any displacement of the ring, the operators used two loose nonresorbable stitches.
Patients were randomly assigned into 2 groups: Group A, including 25 patients (16 females; nine males) with obesity undergoing standard LSG, and Group B, including 25 patients (14 females; 11 males) with obesity undergoing banded LSG. The primary outcome of the study was to assess the weight loss between the two groups in the midterm, analysing data after a median follow-up of four years. Secondary endpoints were the evaluation of complications and resolution of obesity-related comorbidities.
In Group A, the mean age was 43.7±9.8 years and the mean preoperative BMI was 47.3±6.58, and in Group B 45.7±12.7 years and 45.95±5.85. Twelve patients had preoperative T2DM, seven (28%) in Group A and five (20%) in Group B. Twenty one subjects were on antihypertensive medications, 14 (56%) in Group A and seven (28%) in Group B. Eight patients had a diagnosis of OSAS, six (24%) in Group A and two (8%) in Group B.
One patient developed gastric stenosis following LSG and the sleeve was converted to RYGB. Subsequently, all 49 remaining patients had a follow-up of 48 months, 24 in Group A and 25 in Group B.
After three, six and 12 months the mean BMIs in Groups A and B were 37.86±5.72 and 37.58 ± 6.21 (p = ns); 33.64±6.08 and 32.03±5.24 (p = ns); 29.72±4.40 and 27.42±4.47 (p = ns), respectively, with no statistically significant difference was found between the two groups.
At 36-month follow-up, the mean BMI was 28.02±4.21 in Group A and 24.32±4.54 in Group B (p=0.000205). At the end of four-year follow-up, the mean BMI was 28.80±4.62 in Group A and 24.10±4.52 in Group B (p = 0.00199) (Figure 1).
The excess body mass index loss at 36 months and 48 months was, respectively, 86.29% and 82.75% in Group A and 103.4% and 104.51% in Group B (p<0.001).
The researchers reported “excellent” results in terms of resolution of comorbidities after 4 years in both groups. Six patients in Group A (86% of diabetic subjects) and four in Group B (80%) had a complete resolution of T2DM after six months (p=0.755). Hypertension in the two groups decreased from 56% to 28% of patients in Group A and from 28% to 4% in Group B (p=0.022). After six months from surgery, no patients suffered from OSAS. These results remained stable after one year from surgery.
“LBSG is a feasible procedure with a short learning curve, with no impact on postoperative complications. The banded sleeve seems to be significantly more effective than the standard LSG in terms of weight loss in the midterm follow-up,” the authors concluded. “These encouraging results should open the way to standardise LBSG as a defined procedure in the bariatric community, maybe lowering the need of revisional surgery. Additional prospective studies with larger sample size and adequate follow-up are needed to trace any definitive conclusion.”
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