In a recent study, ‘Banding the Pouch with a Non-adjustable Ring as Revisional Procedure in Patients with Insufficient Results After Roux-en-Y Gastric Bypass: Short-term Outcomes of a Multicenter Cohort Study’, published in Obesity Surgery, researchers from The Netherlands reported the outcomes from the first multi-centre revisional banded bypass procedure in a relatively high number of patients. Bariatric News spoke with one of the paper’s co-authors, Professor Eric Hazebroek (Rijnstate Hospital, Arnhem, The Netherlands), about the aims of the study and the potential of revisional banded bypass procedures in preventing weight regain.
“We wanted to see the effect of banding a pouch in revisional procedures using a non-adjustable ring would have on weight regain,” began Professor Hazebroek. “We know there is some evidence from primary procedures that the placement of a ring (MiniMizer Ring, Bariatric Solutions International) can prevent weight regain over time, but there is a lack of evidence concerning banding the bypass as a revisional procedure. Therefore, we decided to join forces with other hospitals and centres in Europe and pool our data and see what evidence there was to support revisional banded bypass.”
He explained that all patients, to some degree, will regain some weight after surgery. Most weight loss is seen during the first year or two after a procedure, after which a small amount of weight regain is seen. However, there is a wide variation in how that weight regain is presented - some patients will have no difficulty in maintaining a stable weight and other will regain a little weight and some will regain weight so they are back to their pre-surgical weight. He added that there are many factors influencing weight regain such as lifestyle, metabolic or genetic factors, but he also believes that there are some technical or procedural factors.
“As this was a retrospective study, we did not have any detailed information on the patients so we decided to separate the patients into two groups - good responders and poor responders. Some people will have a good initial result and regain weight (good responders) and others a poor result from the start (poor responders) and we do not fully understand why this happens. We perform the same procedure in all patients and yet we see a variation of outcomes. This is not only frustrating for the patients but also for the healthcare providers. However, there is some suggestion that patients who have an initial good result and then regain weight might be better candidates for this type of revisional procedure.
In the study, all patients who presented with weight regain were offered dietary counselling to examine and advise them on their diet and lifestyle patterns (food choices and exercise). If this did not result in any improvement, they were offered the opportunity of a revisional band-bypass procedure. Poor responders (insufficient weight loss) were defined as patients that achieved a total body weight loss (TBWL) <25% and good responders (weight regain) as patients that achieved TBWL>25%.
The study included 79 patients who were divided in 24 (30%) poor responders and 55 (70%) good responders after RYGB. The good responder group had a significantly higher BMI before RYGB and the poor responder group had a significantly higher BMI before revisional surgery. The follow-up rate was 86% (59 patients) after one year and 61% (37 patients) after two years
The paper revealed that after revisional surgery, further weight regain was prevented in 75% of patients resulting in a BMI 33±6 and a limited mean regain of 2.3kg was seen in patients in whom revisional surgery did not prevent further weight regain.
One year after revisional surgery, %TBWL improved by 6% in the poor responder group and 8% in the good responder group resulting in a %TBWL of 14±12% and 34±11% respectively. The results remained stable up until two years after placing the non-adjustable ring. Two years after revisional surgery, 13% of the patients in the poor responder group achieved a %TBWL > 25%, compared with 91% in the good responder group.
Interestingly, 18 (23%) rings were removed after a mean follow-up of nine months and five (6%) were adjusted to a larger circumference. Professor Eric Hazebroek explained that the main reason for band removal or adjustment was dysphagia (n=22) and of the first ten rings placed in each centre, 26% were removed. Although, this percentage decreased to 17% when experience increased (>20 procedures)
“Initially, the number of rings that were removed was quite high and we noticed that the majority of rings were removed in the early cases of the study, suggesting that there is a learning curve, and often the more tighter the rings were closed, the increased likelihood that the ring would be removed,” he added. “When you put the ring around the gastric pouch it looks quite loose and your instinct is to make it tighter, but it is important to remember that the ring is there to prevent pouch dilation and to slow gastric pouch emptying, not as a restrictive measure such as in adjustable gastric banding procedures. Currently, we do not remove as many bands as we reported in this series, primarily because of greater operator experience. It is an important message to surgeons - they should be made aware that it is not necessary to over tighten the ring during placement.”
“The outcomes show there is some merit in the notion that patients who have a good initial response to their surgery, do not seem to be able to counteract their weight regain and in who conservative measures have proved unsuccessful, could be good candidates and benefit from the placement of a ring to prevent further weight regain. It is not a matter of them losing the weight they have regained but preventing further weight regain and the return of co-morbidities,” he concluded. “It is very important that we all document detailed patient information including dietary intake patterns, lifestyle and exercise, as well as technical information, as all these details will help us to understand why some patients regain more weight than others.”