Perspectives on ring-augmented sleeve gastrectomy
- owenhaskins
- May 12
- 8 min read
Professor Jodok Fink, Chief Physician of General and Visceral Surgery at Emmendingen District Hospital, Emmendingen, Germany and Consultant at the University of Freiburg, Department of Surgery, performed his first ring-augmented procedure in 2009, has now performed more than 300 cases and conducted one of the few randomised clinical trials comparing standard sleeve gastrectomy to ring-augmented sleeve. Here, he offers his insights into patient selection, outcomes and reducing complications.
Professor Fink explained that in many centres offering ring-augmented procedures, these are the majority of the cases they do because they are well known for these procedures, and patients go specifically to these centres for this reason. At his centre in Germany, they are known for ring-augmented procedures, and so they regularly have one group of patients that specifically request a ring. Fink’s centre specifically offers a ring to a second group of patients where they think that weight loss may not be optimal, for example, in patients with a BMI above 50 or patients who are not able to move properly due to disabilities, and so have difficulty walking.
“We don’t offer a ring to patients where we expect bad compliance, who are receiving immunosuppressants or to patients with enlarged hiatal hernias. If you look at the data, there are no clear contraindications for ring-augmented procedures. In my experience, a large hernia, more than 3 cm, is at least a relative contraindication for placing a silicone ring. Because we know that even if you do a crural repair during the first surgery, the rate of recurrence of that hiatal hernia is up to 70%. If you then place a ring, the ring typically gets stuck at the hiatus, and these patients suffer from dysphagia. The ring diameter often is not the problem in these cases, but scar formation at the hiatal level may be the cause for that added dysphagia in these patients,” he stated.
He added that in patients undergoing a conversion from a sleeve to a bypass, he would specifically consider placing a ring because of dumping and post-bariatric hyperglycaemia issues in these conversion patients. For patients who have had previous gastric banding, he is somewhat hesitant to place a ring due to the presence of scar tissue. Professor Fink explained that in these cases, there is a tendency to construct a larger pouch despite carefully dissecting all scar tissue away to avoid stapling through the scar tissue. However, the pouch is still usually a bit larger and a bit wider than normal. Therefore, he rarely places a ring in such cases.
Outcomes
The Freiburg team published the results of their single-centre, prospective, randomised controlled trial that compared standard LSG with ring-augmented LSG three years after surgery(1). Fink later published a follow-up analysis covering five-year outcomes(2). The study included 94 patients (47 in each group). There were no significant differences in patient characteristics between the groups, although there were more women and patients with diabetes in the ring-augmented group, and patients in this group also had a slightly higher average preoperative BMI. Overall, the outcomes showed that ring-augmented sleeve gastrectomy resulted in better weight loss and no change in surgical complications compared to standard laparoscopic sleeve gastrectomy. The excess weight loss in the per-protocol population at five years was 63.7% in the ring-augmented group, compared with 54.9% in the standard LSG group. Both groups demonstrated remission in T2DM (n=7 (63.6%) and n=6 (66.7%), respectively.
Consistently throughout the study, patients in the ring-augmented group reported a higher rate of regurgitation compared with the standard LSG group. However, patients in the ring-augmented group did not report a higher frequency of reflux symptoms compared with the LSG group. The rate of late surgical complications was similar between the groups. However, a large percentage of patients in both groups experienced Vitamin D (BSG 41%, LSG 47%) and folic acid (BSG 35%, LSG 40%) deficiency. Iron deficiency was more prominent following the ring-augmented procedure (27% vs. LSG 7%). Interestingly, when they compared patient subgroups, it appeared that the major difference in weight loss was from patients with a BMI>50 kg/m2.
“The quality of life in our study was always better in the ring-augmented sleeves – most likely because they have more weight loss, and bariatric patients tend to be more satisfied when they experience more weight loss. Regarding comorbidities, to the best of my knowledge, none of these studies could really show a higher resolution of comorbidities. But all of the studies that have been published are quite small, 100 patients or so, and it’s very hard to show a statistical difference in this small patient collective. But, I think if you produce better weight loss, that is a sustained better weight loss, eventually, if the numbers are high enough, then the resolution of comorbidities would be better in that group. We are now preparing a retrospective analysis of our first group of ring-augmented sleeve gastrectomies. We look forward to publishing the ten-year outcomes.”
“Some of our patients do experience a degree of regurgitation and vomiting, but in most cases, this is due to poor eating habits rather than the Ring itself. If the patients alter their eating habits – avoid certain foods, chew their food thoroughly, eat smaller portions – regurgitation and vomiting is usually resolved.”
Interestingly, he initially thought that the main benefit of placing a ring was a lesser amount of weight recurrence, but his own data and most of the published data do not show that, at least for ring-augmented sleeve patients. He believes the better outcomes are because of the extra weight loss they have in the first two years, compared to standard sleeve patients. Conversely, he noted that for ring-augmented Roux-en-Y gastric bypass, there is more than one publication showing these patients regain less weight than ring-augmented sleeve patients.
“If you look at our data, just looking at the curves, these patients have extra weight loss in the first two years and then weight recurrence is rather similar, at least in our group of patients.”
Avoiding complications
“Regarding complications, for me the worst complication is slippage and migration. Both of them are severe. In ring-augmented sleeves, I’ve seen two slippages, both of which were quite acute, where the Ring moved all the way through to the antrum. Essentially, what happened is the Ring stays in the same place at the lesser curvature, but the staple line just more or less moves upwards through the Ring and then the stomach blood supply may be impaired. This was not the case in these two cases, but it is a potential risk,” he explained. “I have seen one case of Ring migration in a sleeve patient who was on dialysis years after placing the Ring. I have seen a few more in gastric bypass patients, but if they migrate in a gastric bypass, they typically migrate distal to the anastomosis. Most likely, these Rings have been placed too close to the gastrojejunostomy and then later migrated through the jejunum. If you properly place the Ring in a gastric bypass, the risk of migration is very low.”
When he first started to perform ring-augment procedures, he would close the Ring at a circumference of 6.5 cm and place it 5 to 6 cm below the gastroesophageal (GE) junction(3). However, due to cases of regurgitation, they adapted their technique to implant them 3 to 4 cm below the GE junction – measured at the small curvature side – and now in the vast majority of cases close the Rings at a circumference of 7.5 cm(1,4).
“Essentially, it is how the stomach is configured. Sometimes you have a lot of fatty tissue around the stomach, or the stomach wall is quite thick. In these cases, I typically do 7.5 cm or even 8 cm. For example, if you have a 25-year-old woman with a BMI of 40 asking for a ring, a closure of 7.5 cm may appear too loose, and if it’s too loose, it immediately flips. So, then I close it a bit more(5). From my experience, the advice I would give regarding placement and closure is ‘not too low and not too tight.’”
Reflux
Professor Fink and his team have looked at reflux and reflux esophagitis rates in his patients, and they have found that there were not more instances of reflux esophagitis, and cases of symptomatic reflux were lower in ring-augmented patients. Although he does not know for certain the exact mechanism involved, he hypothesised that the Ring could be working as a ‘reflux barrier’ in the sleeve. However, he cautioned that placing a ring is ‘not an anti-reflux procedure’, rather, his data show that the Ring does not cause reflux.
“Some of our patients do experience a degree of regurgitation and vomiting, but in most cases, this is due to poor eating habits rather than the Ring itself. If the patients alter their eating habits – avoid certain foods, chew their food thoroughly, eat smaller portions – regurgitation and vomiting is usually resolved,” he noted. “In our randomised control trial, we found the rate of frequent regurgitation was rather similar in both groups. I think instinctively, in cases of regurgitation, you always think it is the ring. But how can you prove that it’s not the Ring? It’s almost impossible. In the end, if we have somebody with significant regurgitation, we take out the Ring and see what happens. Enlarging the Ring diameter may be an option in selected patients.”
“For a patient with weight recurrence and who wants a second procedure, the body of data for revisionary ring-augmented sleeve gastrectomy is small, but after gastric bypass surgery, I think performing a pouch resizing and placing the Ring is a safe and effective option.”
Professor Fink concluded that many patients experience weight recurrence, especially after sleeve gastrectomy, and he believes that the ring-augmented sleeve procedure has better long-term outcomes with an acceptably low risk of complications, compared with several alternatives.
“If a patient has weight recurrence, there are several options available – you could prescribe GLP-1 receptor agonists that might give you 5 to 15% extra weight loss – but this is in the same range as a primary ring-augmentation would give you. The problem is they need to continue taking GLP-1s because as soon as they stop, they start to regain. At least in Germany, the patients pay for the GLP-1 themselves, so the ongoing costs are a significant issue,” he explained. “Revisional surgery would be another option. But sufficient weight loss via revisional surgery is not guaranteed and can come with additional complications such as micronutrient and macronutrient malabsorption, depending on the type of surgery. Overall, it is about discussing with the patients which options are available, outlining potential complications and recommending what is medically preferable. For a patient with weight recurrence and who wants a second procedure, the body of data for revisionary ring-augmented sleeve gastrectomy is small, but after gastric bypass surgery, I think performing a pouch resizing and placing the Ring is a safe and effective option.”
References
Fink JM, Hetzenecker A, Seifert G, Runkel M, Laessle C, Fichtner-Feigl S, et al. Banded Versus Nonbanded Sleeve Gastrectomy: A Randomized Controlled Trial With 3 Years of Follow-up. Ann Surg. 2020;272(5):690- 5. Epub 2020/07/14. doi: 10.1097/SLA.0000000000004174. PubMed PMID: 32657920.
Fink JM, Reutebuch M, Seifert G, Laessle C, Fichtner-Feigl S, Marjanovic G, et al. Banded Versus Non-banded Sleeve Gastrectomy: 5-Year Results of a 3-Year Randomized Controlled Trial. Obes Surg. 2024;34(2):310-7. Epub 20231218. doi: 10.1007/s11695-023-06982-9. PubMed PMID: 38109013; PubMed Central PMCID: PMC10810940.
Fink JM, Hoffmann N, Kuesters S, Seifert G, Laessle C, Glatz T, et al. Banding the Sleeve Improves Weight Loss in Midterm Follow-up. Obes Surg. 2017;27(4):1098-103. Epub 2017/02/20. doi: 10.1007/s11695-017- 2610-0. PubMed PMID: 28214956.
Fink JM, von Pigenot A, Seifert G, Laessle C, Fichtner-Feigl S, Marjanovic G. Banded versus nonbanded sleeve gastrectomy: 5-year results of a matchedpair analysis. Surg Obes Relat Dis. 2019;15(8):1233-8. Epub 2019/07/10. doi: 10.1016/j.soard.2019.05.023. PubMed PMID: 31285129.
Hany M, Berends F, Aarts E, Fink J, EJ GB, Torensma B. Technical Considerations of Ring-Augmented Laparoscopic Sleeve Gastrectomy: A Step-by-step Guide for Ring Placement by Various Experts. Obes Surg. 2025;35(2):655-7. Epub 20250116. doi: 10.1007/s11695-025-07674-2. PubMed PMID: 39821894; PubMed Central PMCID: PMC11836129
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