Ring-augmented procedures for revisions and conversions
- owenhaskins
- May 12
- 7 min read
Updated: May 13
The number of patients undergoing revision or conversion bariatric procedures has been reported to be as high as 28%(1), however numbers vary greatly between centres and countries. Nevertheless, there is a clear need to provide safe and effective surgical solutions in this group of patients. According to Dr Evert‑Jan Boerma, a bariatric surgeon from the Zuyderland Medical Center in Heerlen, The Netherlands, ring-augmented procedures for conversion or revision surgeries are safe and result in better outcomes than comparable non-ring-augmented procedures.
Dr Boerma began by explaining that he first started using the MiniMIZER Ring in 2016 and has since performed over 2,000 primary procedures, approximately 300 conversion surgeries and around 80 to 100 revision cases with the MiniMIZER Ring. At his centre, they recommend ring-augmented procedures to patients in all types of bariatric surgery: primary surgery, conversion surgery and revision surgery.
“Essentially, there are two main reasons why patients require revision or conversion: they either present with symptoms, such as gastroesophageal reflux (GERD) or dysphagia, or weight issues such as poor initial weight loss or recurrent weight gain. For sleeve patients who present with symptoms, we usually convert the sleeve to a ring-augmented Roux-en-Y bypass, which, in my experience, usually solves the majority of problems. I would estimate 50 % of patients who require conversion surgery present with symptom issues and 50% with weight issues. For the revision procedure, the majority present with weight issues. Of course, some patients present with both symptoms and weight issues, as it is often the case that the symptoms are associated with their weight issues.”
He said that the choice of which revision or conversion procedure to perform depends on the primary surgery. However, he has a preference to convert lap banding or sleeve procedures to a ring-augmented Roux-en-Y bypass. Adding that converting from a band to a sleeve is going from one restrictive procedure to another restrictive procedure, and the presence of scar tissue from the band tends to make a bypass an easier and safer procedure. He added, for patients who have had lap band or sleeve (with GERD), surgeons should also be aware of the likely presence of hiatal hernia and perform a cruraplasty if needed.
“When reporting the outcomes from revision or conversion surgery, I think it is very important to report on the total weight loss from the original primary procedure, not just the weight loss resulting from the revision or conversion procedure. If we don’t describe the original weight loss and we are only describing the weight loss after the secondary procedure, we are only telling part of the story."
However, in some rare cases, they do convert a sleeve to a single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) procedure, usually in primary nonresponse patients who have lost weight, but not enough. If however the patient had a good response after the sleeve, but suffers from recurrent weight gain (secondary non-responder) a conversion to a ring-augmented Roux-en-Y bypass is preferred as results are positive and the possible long-term complications of SADI-S such as diarrhoea and malnutrition can be avoided. Although converting a sleeve to a bypass is a relatively straightforward procedure, he noted that patients with a prior vertical banded gastroplasty (VBG) offer a more challenging case due to a larger amount of scar tissue resulting from open surgery.
Cumulative weight loss
Dr Boerma and his colleague, PhD student Kayleigh van Dam, have published several papers on conversion procedures, including sleeve to ring-augmented bypass(2) and VBG to ring-augmented bypass(3) and will soon publish their paper on lap band to ring-augmented bypass.
“When reporting the outcomes from revision or conversion surgery, I think it is very important to report on the total weight loss from the original primary procedure, not just the weight loss resulting from the revision or conversion procedure. If we don’t describe the original weight loss and we are only describing the weight loss after the secondary procedure, we are only telling part of the story. For example, if a patient has 60% total weight loss and regains 50%, it’s very different from the patients who only lost 20%. Ultimately, results from the secondary surgery will be quite different. This is why we introduced the term ‘cumulative total weight loss’(4), which adds weight loss from both primary and secondary procedures. It’s not a ground-breaking or very new concept, but a lot of people, when they publish their data, only look at their weight loss data after the secondary procedure. And then you’re comparing apples with pears. There is a perception that secondary procedures are inferior to primary procedures, but if you are only reporting the results from one procedure and do not tell the full story. Our data show that the cumulative total weight loss from VBG to ring-augmented bypass, lap band to ring-augmented bypass and sleeve to ring-augmented bypass are all around 32%. These results are comparable to results from a primary non-Ring-augmented Roux-en-Y bypass.”
“From a conceptual point of view, I think resizing the pouch reboots the bypass and gives additional restriction. It returns restriction and adding the Ring impacts their satiety. More importantly, it prevents the pouch from expanding again, so we believe the Ring prevents secondary expansion.”
In discussing his technique for revision procedure, he emphasised the importance of the pouch. In a paper his team has recently submitted for publication, they found that resizing the pouch and adding a ring resulted in an additional 15% total weight loss after one to two years in patients who regained their weight after gastric bypass surgery.
“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. When we re-sleeve the pouch, we put in a 40 French tube, we completely free up the pouch from adhesions and the remnant stomach, and then we really make a nice slim pouch, almost a primary pouch again. And then we place a ring around it. From a conceptual point of view, I think resizing the pouch reboots the bypass and gives additional restriction. It returns restriction and adding the Ring impacts their satiety. More importantly, it prevents the pouch from expanding again, so we believe the Ring prevents secondary expansion.”
Complications
Regarding ring-related complications, his data show that the number of ring-related complications is low. Only three out of 50 patients in his series of sleeve to bypass conversion reported a ring-related problem(2). In an additional series of lap band to bypass conversions (unpublished data), only one patient out of the 240 (0.4%) reported a ring-related issue. And in a series of patients converted from VBG to ring-augmented bypass3 there were no ring-related complications from 105 procedures.
Tips and tricks
“I think there are two important lessons we learned throughout the years using the MiniMIZER Ring. Firstly, where you place the Ring around the pouch that is, the distance between the gastroesophageal junction and the Ring, and the gastrojejunostomy and the Ring. At first, we thought it should be around 1-2 cm above the gastrojejunostomy, but now we know that the closer it is to the gastrojejunostomy, the higher the chance of a complication. So now we place it higher. We have also learnt to make a longer pouch and increase the distance between the gastroesophageal junction and the gastrojejunostomy. I think it’s important to place it as far as way as possible from the gastrojejunostomy.”
The second important consideration is the circumference size of the closed Ring. Initially, his team used a circumference of 6.5 cm in females and 7 cm in males; however, they now mostly use 7 cm in females and 7.5 cm in males. The ‘golden rule’ is that the Ring should be loose around the pouch. Therefore, the Ring should not be ‘snug’, but relatively loose. He advised that there should be enough room between the pouch and the Ring to put at least an instrument through. In his experience, if the Ring is too tight, there is a higher risk of dysphagia or, in rare cases, erosion. He also said that by making a standardised calibrated pouch (with a 40 French tube), then a calibrated ring circumference works. The only difference is the thickness of the gastric wall, which tends to be a bit higher in males than in females. He explained that the problem with not using fixed diameters is that if a surgeon performs an ‘ad hoc’ calibration, then ultimately that surgeon will never learn which circumference size works. For this reason, his team follows a protocol of creating a very strictly calibrated pouch.
“We know bariatric surgery is the most effective treatment for obesity and its related diseases. In my opinion, ring-augmented procedures actually strengthen the restrictive component of a sleeve or bypass. In addition, it also offers additional satiety to patients. The ultimate goal of bariatric surgery is longstanding, long-term, sustained weight loss. Our protocol is to perform ring-augmented procedures in all our primary cases, and when we look at our data and compare it to centres who do not perform ring-augmented procedures, our patients have better long-term outcomes, not only at five years, but at ten years and maybe even longer,” he concluded. “As with any procedure, there is the risk of a number of added complications, but this percentage in experienced hands is very low and is usually very easy to rectify. For example, the worst complication we see with a MiniMIZER Ring is erosion, which is very, very, rare, but it is very easy to treat with an endoluminal stent. Whereas, I find that erosion with a lap band is always a nightmare to treat. Overall, ring-augmented procedures are safe with a very low complication rate and offer better outcomes for our patients in the long term, when compared to non-ring-augmented procedures.”
References
Altieri MS, Yang J, Nie L, Blackstone R, Spaniolas K, Pryor A. Rate of revisions or conversion after bariatric surgery over 10 years in the state of New York. Surg Obes Relat Dis. 2018 Apr;14(4):500-507. doi: 10.1016/j.soard.2017.12.019. Epub 2017 Dec 29. PMID: 29496440.
van Dam KAM, de Witte E, Broos PPHL, Greve JWM, Boerma EG. Short-term safety and effectiveness of conversion from sleeve gastrectomy to ring-augmented Roux-en-Y gastric bypass. BMC Surg. 2024 Sep 19;24(1):266. doi: 10.1186/s12893-024-02552-7. PMID: 39300438; PMCID: PMC11411827.
van Dam KAM, Jense MTF, de Witte E, Fransen S, Boerma EG, Greve JWM. Laparoscopic Conversion of Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass Gives Better Result Compared to an Open Approach. Obes Surg. 2023 Jun;33(6):1746-1753. doi: 10.1007/s11695-023-06574-7. Epub 2023 Apr 12. PMID: 37043139.
van Dam KAM, Verkoulen GHJM, de Witte E, Broos PPHL, Greve JWM, Boerma EG. Setting the Standard: Cumulative Total Weight Loss as Outcome Measure After Secondary Bariatric Metabolic Surgery. Obes Surg. 2024 Sep;34(9):3521-3522. doi: 10.1007/s11695-024-07398- 9. Epub 2024 Jul 23. PMID: 39042308.
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