Pouch revision plus raRYGB is a promising approach for recurrent weight gain

Pouch revision in combination with ring-augmented Roux-en-Y gastric bypass (raRYGB) – using a MiniMizer Ring - appears to be a promising approach for managing patients with a suboptimal clinical response or recurrent weight gain after RYGB, which results in significant additional weight loss with a low complication rate, according to researchers from The Netherlands.

Intraoperative image presenting the MiniMizer ring placed on a revised gastric pouch. The MiniMizer is placed around the pouch with a circumference of 7.0 cm for females and 7.5 cm for males, 2–3 cm below the gastro-oesophageal junction and at least > 2 cm above the gastro-jejunal anastomosis

Although RYGB is proven to be one of the most effective surgical procedures for the long-term management of severe obesity, according to the literature 10–35% of patients have a suboptimal clinical response (less than 20% total weight loss (TWL)) or suffer from recurrent weight gain 5–7 years post-RYGB, often resulting in additional surgery.

The underlying causes are multi-factorial and include anatomical alterations (eg. dilatation of the gastric pouch or dilatation of the gastro-jejunal anastomosis) and an inability to adopt a healthy lifestyle. According to Dr Evert‑Jan Boerma, a bariatric surgeon from the Zuyderland Medical Center (ZMC) in Heerlen, The Netherlands, and co-author of the study, resizing the pouch can improve early satiety and prevent overeating and the addition of a non-adjustable silastic ring (the MiniMizer Ring) enhances early satiety and prevents secondary pouch dilatation.

Evert‑Jan Boerma

“From a conceptual point of view, I think resizing the pouch reboots the restrictive component of the gastric bypass and offers additional weight loss. Adding the Ring also impacts their satiety. But more importantly, it prevents the pouch from expanding again. So, we believe the Ring prevents expansion and in that way maintains the weight loss and prevents recurrent weight gain on the long term.”

This study aimed to determine the effect of pouch revision in combination with the placement of a MiniMizer ring in patients with a suboptimal clinical response or recurrent weight gain after RYGB on weight loss after two years of follow-up. Furthermore, predictors of outcome, such as prior weight loss results, were analysed.

Data was prospectively collected and retrospectively analysed on all consecutive primary RYGB patients who underwent a pouch revision in combination with placement the MiniMizer Ring, between January 2016 and December 2021 at ZMC. The inclusion criteria comprised of previous RYGB patients who experienced either suboptimal clinical response or recurrent weight gain after primary RYGB surgery:

• A suboptimal clinical response was defined as patients who were in the lowest quartile of weight loss after RYGB surgery.

• Patients with recurrent weight gain were patients who initially achieved sufficient weight loss after RYGB surgery, but suffered from recurrent weight gain of >10% of the lost weight.

"That’s what makes our technique a bit different from what other surgeons do. Other teams either re-sleeve their pouch or add a ring – we do both,” he explained. “Before we re-sleeve the pouch, we completely free up the pouch from adhesions and the remnant stomach, we then put in a 40 French orogastric tube, and make a really nice slim pouch, just as our primary pouches. And then we place a ring around it and fixate it to the lateral stapleline.”

Outcomes

In total, 36 patients with a mean BMI of 39.4 kg/m2 (range 27.9–56.6) at screening for revision were included. Of the 36 patients, 7 (19.4%) were male and 29 (80.6%) female, with a mean age of 49 years (range 23–63) at time of revision. The indication for revisional surgery was recurrent weight gain in 33 patients (91.7%), suboptimal clinical response in 1 (2.8%) or both in 2 patients (5.6%). A mean gap of nine years (range 2–33) was present between the primary RYGB and revisional surgery. The primary RYGB was performed as a laparoscopic procedure in the majority of patients (83.3%). A mean %TWL of 36.0% was achieved after the primary RYGB. On average, patients gained 26.1 kg (range 4.5–80.1) in weight (18.7 mean %TWL) before the revisional procedure.

A %TWL of 12.2% (EWL% = 32.9) and 13.5% (EWL % = 48.0) was achieved at 12 months and 24 months after revisional surgery respectively (Figure 1). The difference between mean %TWL at screening and 1- and 2-year follow-up points was statistically significant with a p<0.001 at both time points. Superior weight loss patients (%TWL ≥ 35) achieved a %TWL of 16.5, and patients from the suboptimal group (%TWL < 35) achieved a %TWL of 7.1 at 24 months post-revisional surgery. The differences among both groups were not statistically significant (p=0.133 at 12 months, p = 0.202 at 24 months), probably due to small numbers.

Figure 1: Weight loss post-revisional surgery. One patient had no post-RYGB weight and could therefore not be included in either the superior or suboptimal group

Cumulative weight loss

A cumulative %TWL of 26.7% (EWL% = 56.9) and 28.7% (EWL% = 60.0) was achieved at 12 months and 24 months after revisional surgery respectively. Superior responders (%TWL ≥ 35) and suboptimal responders (%TWL < 35) achieved a cumulative %TWL of 33.9% and 17.5%, respectively, at 24 months post-revisional surgery (Figure 2). Independent sample Mann–Whitney U testing was performed; the differences among both groups were statistically significant (p<0.001 at 12 months, p=0.045 at 24 months).

Figure 2: %Total weight loss from screening for primary procedure until 2 years after revisional procedure. One patient had no post-RYGB weight and could therefore not be included in either the superior or suboptimal group

There were no short-term complications (< 30 days postoperative) with a classification of Clavien Dindo 3b or higher, such as anastomotic leakage or bleeding. In terms of long-term complications, three patients suffered from dysphagia (8.3%). However, no organic explanation was appreciated on a barium swallow test. There were no cases of dysphagia for which the ring had to be removed. There was one ring-related long-term complication which was scored as a Clavien Dindo 3b or higher: the patient required repositioning of the MiniMizer due to gastric prolapse through the ring . No ring erosion occurred in this study population. Additional surgery was performed in four patients: three patients underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis and one patient underwent laparoscopic incisional hernia repair.

“To our knowledge, this is the first study reporting on the combination of pouch revision and MiniMizer placement as a revisional procedure for suboptimal clinical response or recurrent weight gain after RYGB,” Dr Boerma concluded. “Future research should focus on larger, prospective studies, if possible multi-centre, to support the findings of this study. Additionally, long-term follow-up beyond two years would provide valuable insights into the durability of weight loss outcomes and potential long-term complications.”

The findings were reported in the paper, 'Pouch Revision in Combination with Placement of a MiniMizer Ring as a Revisional Procedure in Patient with Suboptimal Clinical Response or Recurrent Weight Gain After RYGB', published in Obesity surgery. To access this paper, please click here