IFSO ‘cautiously’ supports the selective use of ring augmentation in both primary and revisional MBS

In a recent position statement, the International Federation for the Surgery and Other Therapies for Obesity (IFSO) has ‘cautiously’ supported the selective use of ring augmentation (ra) in both primary and revisional metabolic bariatric surgery (MBS), particularly for Roux-en-Y Gastric Bypass (raRYGB).

The findings were reported in the paper, ‘Ring-augmented Metabolic Bariatric Surgery Procedures GRADE based International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Position Statement’, published on behalf of the IFSO Ring Augmented Metabolic Bariatric Surgery Procedures Task Force, in Obesity Surgery.

“The findings demonstrated that ring augmentation in bariatric procedures may provide superior or comparable weight loss outcomes compared to standard procedures, although results were heterogenous and evidence quality varied,” the paper states. “Ring-related complications and removal rates were generally low. While further high-quality, long-term studies are needed, current evidence cautiously supports selective use of ring augmentation in both primary and revisional MBS, particularly for raRYGB.” 

Although MBS is the most-effective treatment for obesity and its related metabolic disorders, recurrent weight gain and long-term complications remain a concern for patients. Ring augmentation has been proposed as a surgical strategy to enhance long-term weight maintenance, by placing of a silicone ring around the gastric pouch or sleeve to enhance satiety during meals without causing constant mechanical restriction. It is hypothesised that after raRYGB, when the pouch expands against the ring the mechanical interaction triggers neural signals that promote a feeling of satiety.

As the number and type of ring augmentation procedures expands, IFSO believes that there is a need for a clear, evidence-based framework to guide clinical practice. Therefore, the recent position statement sought to categorise ring augmented MBS and to review current evidence on outcomes such as weight loss, complication rate and ring removal rate.

The comprehensive literature search consisted of ring-augmented procedures, including RYGB, SG and OAGB, and the outcomes focused on postoperative weight loss (as either %TWL of %EWL) and complication rates including ring removal.

Outcomes

In total, the review included 29 articles (6,999 patients) were included, seven were RCT and 22 were observational studies. Fourteen studies reported outcomes of raRYGB including a total of 4,330 patients. Of these, ten studies directly compared raRYGB to standard RYGB and were included in the analysis. The remaining four studies compared raRYGB to SG or OAGB. For the included studies, the ring types varied and included MiniMizer, Silastic rings (Bariatric Solutions) and GaBP ring (Baria Tec). Across the studies, the raRYGB had more %EWL or %TWL than the standard procedure. The pooled analysis showed a benefit of ring augmentation with a mean difference (MD) of 7.9% (95% CI 1.9–13.9).

For raSG, eight studies (1 RCT and 7 observational), were analysed. All studies showed higher weight loss percentages for the raSG group, compared to standard SG. The meta-analysis showed a not significant trend in favour of raSG with a pooled mean difference of 4.04% (95% CI -5.31–13.38, p=0.2040).

For raOAGB, three studies (1 RCT and 2 observational, 231 patients) reported outcomes of raOAGB compared to standard OAGB. However, due to the limited number of studies with adequate data of weight loss outcomes no meta-analysis was performed for raOAGB.

For ra revisional/conversional surgery, four studies (1 RCT and 3 observational), were reviewed and reported cumulative %TWL values ranging from 26.9% to 32.9%, indicating a generally consistent trend across studies.

Ring-related complications

Ring-related complications and the removal rate were reported in most of the included studies, with removal rates ranging from 0% to 21.7% with most studies (13/21) reporting rates of 5% and less. In total, 129 rings were removed among 2,041 patients during follow-up (6.32%).

“Ring augmented Metabolic Bariatric Surgery appears to be a promising but not yet fully validated strategy to enhance long-term weight loss outcomes. The most consistent evidence exists for raRYGB, which shows superior weight loss outcomes compared to standard RYGB. For ring augmented SG and OAGB, evidence is limited, heterogeneous, and requires cautious interpretation. In revisional MBS, preliminary findings are encouraging, but current evidence is insufficient for routine recommendations,” the statement concluded. “Further high-quality, long-term RCTs with standardised outcome reporting are essential before broader adoption. In revisional MBS ring augmentation shows encouraging results with cumulative %TWL comparable to those of primary procedures. Importantly, the generally low complication and removal rates support the safety of ring augmentation when applied selectively. However, to validate and strengthen these findings and enable standardised outcome reporting high quality, long-term comparative randomized controlled trials are needed.”

Recommendations

The IFSO Ring Augmented Metabolic Bariatric Surgery Procedures Task Force made the following recommendations:

• In primary MBS, ring augmentation may be considered selectively, particularly for patients at high risk of recurrent weight gain, but only after discussion of limited long-term evidence.

• In revisional or conversional MBS, the addition of a ring should not be routinely recommended. When considered, it should be performed only in specialised centres with structured follow-up, ideally within clinical trials or registries.

• Ring-augmented procedures in revisional settings should be limited to prospective data collection, preferably under IRB approval.

• Further well-designed, long-term RCTs are strongly needed to clarify the role of ring augmentation, particularly in revisional and conversional surgery, where evidence is currently sparse and of low certainty

  
  

The findings were reported in the paper, ‘Ring-augmented Metabolic Bariatric Surgery Procedures GRADE based IFSO Position Statement’, published in Obesity Surgery. To access this paper, please click here