Ring-augmented gastric bypass: Maintaining the restrictive mechanism of a gastric bypass
- owenhaskins
- May 12
- 6 min read
Updated: May 13
In 1997, Dr Bruno Dillemans from the Center of Obesity Surgery in the AZ Sint-Jan Hospital in Bruges, Belgium, was one of the first surgeons to perform ring-augmented gastric bypass in Europe. In this interview, he explains the purpose of the ring-augmented procedure, offers some fascinating insights into how surgeons can improve the procedure and the importance of retaining the restrictive mechanism of a gastric bypass.
“Some of the first banded procedures were carried out by Capella(1) and included a very long but narrow gastric pouch. It was an open retrocolic retrogastric bypass, and the concept was to reinforce the end of the gastric pouch to yield better long-term results,” he explained. “The only drawback or shortcoming with that type of procedure at that time was that the circumference of that ring was too small. The weight loss was very good, but frequently resulted in gastric outlet obstruction, so the rings had to be removed because the patients had a very poor quality of life in terms of vomiting and GERD.”
In subsequent years came the emergence of laparoscopic surgery, the Fobi Ring from MAL Fobi and a lot of lessons were learnt regarding circumference, placement and most importantly, the impact of the procedure on the long-term maintenance of weight loss.
“The rings nowadays are much better as they have four different settings with the possibility to tailor the circumference according to the local situation. In most cases, I set the size at 7.5 or 8 cm for both bypass and sleeve. I am just trying to get a relatively good quality of life on the one hand and a better preservation or consolidation of the weight loss over time on the other hand.”
“The main reason I see ‘failures’ or unsuccessful results in the long term is the lack of maintenance of this restrictive, satiety mechanism of the bypass or sleeve.”
At Dr Dillemans’ centre, they offer ring-augmented gastric bypass to younger patients (less than 50 years old) who present with a BMI of 45 or more or a BMI of 40 with a serious comorbidity, because this ring-augmented procedure yields better results in the long term. He explained that lengthening the biliopancreatic limb (BPL) is also a very good method in the long term; however, especially for young female patients, lengthening the BPL can result in iron depletion and anaemia. Therefore, the addition of a ring to the bypass adds satiety or restriction in the long term. In elderly patients, he prefers to lengthen the bilio pancreatic limb because the risk of iron depletion and nutritional deficiencies is less important.
“The outcomes with the new rings are very good, as has been shown in numerous randomised studies between ring and non-ring procedures from Lemmens, Bandari, Fink, etc. Interestingly, the longer the patients are followed (five to ten years), the greater the difference in achieved weight loss between the ring-augmented and non-ring procedures,” he added. “So, the Ring achieves its purpose in consolidating better the restrictive/satiety part of the bypass or sleeve, which is otherwise doomed to gradually fade away in time.”
He cited the randomised control trial by Luc Lemmens(2) that reported no significant differences between a ring-augmented group and a non-ring group in the first year following gastric bypass surgery in terms of weight loss and %EWL. However, %EWL at five years was 65.2 ± 20.0% in the group without the ring but 74.0 ± 15.1% in the group with the ring (Figure 1). In addition, %BMI loss at five-years post-surgery was significantly higher in the ring group (p<0.0001, Figure 2).
“I was afraid that we might be dealing with the complications (gastric outlet obstruction) we had with the Capella procedure, but we have not seen that. I also thought we might see more GERD, but not only do I not see it in my clinic, this was also reported in two studies by Jodok Fink(3,4). In these papers comparing ringed sleeves versus non-ringed ones, he showed not only that the weight loss of the sleeve with a ring is much more superior to a sleeve without a ring, but additionally, and amazingly, there was no increase in GERD in the ringed sleeve group. Since then, we have included the ring-augmented sleeve in our surgical armamentarium, more specifically for our super-obese group of patients.”
When performing a ring-augmented bypass, Dr Dillemans makes the pouch slightly longer and prefers to make a gastrojejunostomy with a circular stapler. He acknowledges that this is a bit more technically demanding and more expensive, but it is more appropriate since it is easier and safer to put the Ring 2 cm above the anastomosis. In case of the more commonly performed linear stapled gastrojejunostomy, the jejunum dorsally expands like a tongue shaped spur 3 cm higher cranially, which makes it more tedious to put the Ring around the stomach and not around a part of the anastomosis or the jejunum, which has to be avoided in all circumstances to prevent migration.
He added that he prefers not to fix the Ring itself on the gastric wall of the pouch of a gastric bypass as this creates a pressure point that might promote ring migration. In addition, if the Ring is fixed on the gastric pouch with a nonresorbable stitch, it’s very difficult to retrieve it by endoluminal means in case of migration without causing a tear or perforation of the pouch.
“So, the trick that we have developed and embraced is – and a lot of surgeons visiting me are taking this back to their centres – we use the remnant stomach of the gastric bypass to fix it on the lateral side of the gastric pouch, above and underneath the location of the Ring to prevent ring slippage. But we take care not to align both staple lines in order to prevent the development of a gastrogastric fistula. By putting in those stitches, the Ring cannot slip but remains very loose around the gastric pouch.”
In his centre, they perform five or six procedures a week due to weight recurrence after an initial sleeve or gastric bypass, and the majority of patients complain about a loss of restriction and satiety; either presenting by polyphagia or hyperphagia or a combination of both. So, he believes that it is better to work on prevention in the first instance, rather than adding a ring in a second procedure when after some years, the pouch is dilated.
“If you ask, ‘What are the working mechanisms of gastric bypass?’ Normally, we have three working mechanisms. First is restriction or satiety, second is hypo (mal) absorption, and third is hormonal. But as a lot of studies have shown that the most important part is still the restrictive or satiety-inducing component,” Dr Dillemans concluded. “The main reason I see ‘failures’ or unsuccessful results in the long term is the lack of maintenance of this restrictive, satiety mechanism of the bypass or sleeve.”
References
Capella RF, Capella JF, Mandec H, Nath P. Vertical Banded Gastroplasty-Gastric Bypass: preliminary report. Obes Surg. 1991 Dec;1(4):389-395. doi: 10.1381/096089291765560782. PMID: 10775940.
Lemmens L. Banded Gastric Bypass: Better LongTerm Results? A Cohort Study with Minimum 5-Year Follow-Up. Obes Surg. 2017 Apr;27(4):864-872. doi: 10.1007/s11695-016-2397-4. PMID: 27714527; PMCID: PMC5339319.
Fink JM, von Pigenot A, Seifert G, Laessle C, FichtnerFeigl S, Marjanovic G. Banded versus nonbanded sleeve gastrectomy: 5-year results of a matched-pair analysis. Surg Obes Relat Dis. 2019 Aug;15(8):1233- 1238. doi: 10.1016/j.soard.2019.05.023. Epub 2019 May 24. PMID: 31285129.
Fink JM, Hetzenecker A, Seifert G, Runkel M, Laessle C, Fichtner-Feigl S, Marjanovic G. Banded Versus Nonbanded Sleeve Gastrectomy: A Randomized Controlled Trial With 3 Years of Follow-up. Ann Surg. 2020 Nov;272(5):690-695. doi: 10.1097/ SLA.0000000000004174. PMID: 32657920.
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