Despite the rise of laparoscopic sleeve gastrectomy (LSG) world over in recent years, there are concerns about the long-term effectiveness of the procedure and the number of patients presenting with gastro-oesophageal reflux disease (GERD) and weight regain in the longer term. Bariatric News spoke with Dr Muffazal Lakdawala (Chairman Institute of Minimal Access Surgical Sciences and Research Centre Saifee Hospital, Director Digestive Health Institute and Chief Minimal Access Oncology, Mumbai, India) current President of IFSO – Asia Pacific Chapter, who believes that the banded gastric bypass should now be the new gold standard bariatric procedure for most bariatric surgeons.
For several years, Dr Lakdawala performed LSG on the majority of his patients, however, after reviewing his long-term data he saw a trend of weight regain in more than 60% of his LSG patients after the first two years of surgery and a rise in the number of patients presenting with GERD. As a result, almost 80% of his patients now receive a banded bypass.
“I brought about changes in the procedure I offered patients in my practice was because when we reviewed the long term (more than five year) outcomes of patients with LSG 60% presented with substantial weight regain, but a large number of patients were troubled with persistent GERD,” he explained. “In our practice until three years back, most patients did not have a pre-op gastroscopy before surgery, unless it was absolutely indicated, now we perform routine upper gastrointestinal endoscopy on all of our patients. In those patients who are found to have a Hill Classification of Grade 3 (multiple circumferential erosions) or Grade 4 (ulcer, stenosis or oesophageal shortening) or an LA Classification of grading endoscopic oesophagitis of C or D or Barrett’s Oesophagus, we strongly recommend a banded gastric bypass. The reason for picking a banded vs a non-banded gastric bypass is that even in the conventional Roux en Y Gastric Bypass we see long term weight regain and recurrence of T2DM in a few patients, secondary to weight regain."
According to Dr Lakadawala, most bariatric patients have a maladaptive eating behaviour so the optimal surgical option for morbid obesity is to mix restriction with intestinal hormonal factors for best results for long term diabetes remission. He believes that though malabsorptive procedures give the best results their long-term protein and nutritional deficiencies make them not a viable option for a majority of the patients. “Patients who have had a gastric band, a sleeve or a gastric bypass and adopt a very healthy lifestyle and good eating behaviour post op still maintain a good degree of weight loss and resolution of co morbidities. But a majority fail to stick to these habits and have weight regain. This is where I believe the banded bypass offers some success against weight regain. The placement of the MiniMizer Ring (Bariatric Solutions), offers the option of restriction at the level of the Gastric pouch and prevents dilatation of the entire oesophago-gastro jejunal anatomy allowing the patient to consume more and regain weight.”
"Therefore, for me the preferred option is the banded gastric bypass, it is better than the conventional bypass for long-term weight loss and resolution of co morbidities with few additional long term complications. Which is why I believe it is the new gold standard procedure."
In the last four years, Dr Lakadwala has performed approximately 500 banded gastric bypasses and has been using the MiniMizer Ring for approximately two years now. Prior to using the MiniMizer Ring, he was using the Fobi Ring. However he started using the MiniMizer Ring as with this device it was much easier to adjust the outlet diameter from 6.5 to 8.0 to address each individual patients requirements with the same device.The Ring can be tailored to suit several closing positions from the largest to the smallest ring size: from 8.0 cm length (approx. 26 mm internal diameter), to 7.5 cm length (approx. 24 mm internal diameter, 7.0 cm length (approx. 22 mm internal diameter) and 6.5 cm length (approx. 20 mm internal diameter). The MiniMizer Ring also has a soft, blunt, silicone tip that simplifies retrogastric placement.
“For the banded gastric bypass, the only compliant we see from patients is dysphagia in terms of solid foods, especially when they do not chew their food properly, however this is more to do with eating habits so we encourage them to chew their food thoroughly. Otherwise, we have had almost no complications and only one band erosion in four years and no other long-term device-related side-effects.” he added. Although some 80% of his patients now undergo a banded gastric bypass, patients with a low BMI (30-32.5) who are operated specifically for metabolic surgery (type 2 diabetes) patients are not recommend a banded bypass but rather a Roux en Y Gastric Bypass as he believes that the additional long term benefits offered by the ring may not be necessary for this subset of patients.
“Previously in a non-banded Roux en Y Gastric Bypass I used to make a very tiny pouch, just 3cm below the GE junction. After I started doing the banded bypass, I made the length of the gastric pouch a little longer (5 cm). When performing the banded bypass, I create the gastric pouch and then take the loop of the jejunum 100cms away from the Ligament of Treitz to perform a gastric jejunostomy,” he said. “I perform a linear stapled anastomosis 2cms in size and place the Ring after passing the bougie, which is either 36 or 38F in size, through the anastomosis. The Ring is placed at least 2cm to 3cm above the anastomosis. The most important lesson is to have the Ring at least 2cm above the anastomosis. Another tip is to have the ring snug and not too tight around the gastric pouch, this is where the Mini Mizer ring with its option of adjustability helps, one can easily readjust the outlet size.”
He added that in super obese patient with a lot of intrabdominal fat around the Gastric pouch one need not de-fat or devascularize the area on the lesser curve but rather create a window in the fat and easily pass the MiniMizer ring through it. This also holds the Ring in place, eventually after locking the Ring in place he fixed it with one 3.0 prolene stitch after turning the buckle towards the caudate lobe of the live.
His data at one-year showed that the sleeve patients were similar in terms of weight loss as compared to the non-banded or the banded bypass patients, however, at around 18 months both non-banded and banded bypass perform better. Interestingly, he said that the mini-gastric bypass (MGB, or single (one) anastomosis gastric bypass) seems to have the best outcomes of all three procedures in the first 18 months, in terms of weight loss. Post the 2year period the banded bypass is equal to or better than the SAGB/ OAGB. He added that, on an average, his patients see 75% excess weight loss or a total body weight loss of approximately 30-35% four years after a banded gastric bypass.
“It is at the four-year mark the banded gastric bypass seems to move ahead in terms of preventing weight regain compared to the sleeve, non-banded bypass and MGB. When we have seen significant weight regain in sleeve after 4-5 years in super-obese patients, we have converted them from a sleeve to the SADI-S (Single anastomosis duodeno–ileal bypass with sleeve gastrectomy) procedure.”
He is currently collating three-year data on his super-obese patients to ascertain whether the banded bypass maintains weight loss in this group of patients and hopes to publish this data soon.
“In my mind – in terms of resolution of comorbidities – I would recommend a duodenal switch or a SADI-S procedure. However, these are complex malabsorptive procedures and there are certainly concerns regarding nutritional deficiencies following these procedures. The sleeve gastrectomy is a simple procedure, but I suspect the numbers may decline over the next few years as the number of patients with troublesome post-operative instances of GERD increase, as well as long term weight regain starts bothering both patients and surgeons,” he concluded. “Of course, we still do not know the long-term outcomes from the SAGB/ OAGB/ MGB, which is a simpler procedure than a conventional Roux en Y gastric bypass. Therefore, for me the preferred option is the banded gastric bypass, it is better than the conventional bypass for long-term weight loss and resolution of co morbidities with few additional long term complications. Which is why I believe it is the new gold standard procedure.”