Banded versus nonbanded Roux-en-Y gastric bypass: a systematic review and meta-analysis of randomized controlled trials

Short-term safety and effectiveness of conversion from sleeve gastrectomy to Ring augmented Roux-en-Y gastric bypass

BACKGROUND

Weight recurrence, suboptimal clinical response and functional disorder (such as reflux) after a Sleeve Gastrectomy (SG) are problems that may require conversional surgery. For reflux, conversion to Roux-en-Y Gastric Bypass (RYGB) is considered effective. Regarding treatment for suboptimal clinical response, the technique of choice remains a subject of debate. This study aims to evaluate the safety and effectiveness of conversion from SG to Ring-augmented RYGB ( RaRYGB).

METHODS

All laparoscopic SG to RaRYGB conversions performed between January 2016 and January 2022 were included. Primary outcome was percentage total weight loss (%TWL) after 1-year follow-up. Secondary outcomes consisted of cumulative %TWL, complications (with a focus on ring-related complications), and resolution of medical-associated problems.

RESULTS

We included 50 patients of whom 44 were female. Mean pre-conversion BMI was 37.6 kg/m2. All patients have reached the 1-year follow-up point, however 10 were lost to follow-up. After 1-year mean TWL was 17.8% while mean cumulative TWL, calculated from primary SG, was 32%. A total of 10 complications occurred in 8 patients within 30 days, 6 of which were ≤ CD3a and 4 ≥ CD3b. One MiniMizer was removed for complaints of severe dysphagia. Of the 35 medical-associated problems present at screening 5 remained unchanged(14.2%), 15 improved(42.9%) and 15 achieved remission(42.9%).

CONCLUSION

Our series of 50 patients undergoing conversion from SG to RaRYGB is adequate and successful regarding additional weight loss 1 year after conversion, cumulative weight loss, complication rate and achievement of improvement or remission of medical-associated problems.

Long-term Comparative Evaluation of Weight Loss and Complications of Banded and Non-banded Roux-en-Y Gastric Bypass

PURPOSE

The use of a nonadjustable silicone band around the gastric pouch of Roux-en-Y gastric bypass (RYGB) to reduce the recurrence of obesity is still being debated in the literature. The primary objective of this study was to evaluate banded and non-banded RYGB regarding % total weight loss (%TWL) and complications up to 10 years postoperatively and regarding the removal rate of the silicone band.

MATERIAL AND METHODS

A retrospective study of the medical records of all patients submitted to banded and non-banded RYGB between 2000 and 2020 was conducted. Clinical data (age, gender, weight, body mass index-BMI, comorbidities, %TWL, and the prevalence of vomiting) and laboratory data (hemoglobin, serum iron, albumin, and vitamin B12) were obtained preoperatively and at 6 months, 1, 2, 3, 5, 7, and 10 years for both groups and at 12, 15, and 20 years after banded RYGB.

RESULTS

In total, 858 patients underwent RYGB: 409 underwent banded RYGB and 449 underwent non-banded RYGB. In the preoperative period, banded RYGB patients were heavier and had higher rates of hypertension and dyslipidemia. The %TWL was higher in the banded RYGB group up to 7 years. The prevalence of vomiting is much higher in this group, which also had lower laboratory test values. Of the banded RYGB patients, 9.53% had to have the silicone ring removed after presenting complications.

CONCLUSION

Banded RYGB promotes significantly higher rates of TWL at the expense of a higher frequency of food intolerance and vomiting.

Banded One-Anastomosis Gastric Bypass (BOAGB) for Patients Living with Obesity and Extreme Obesity: A Single Institution's Experience

BACKGROUND

The prevalence of patients suffering from extreme obesity (body mass index (BMI) ≥ 50) has significantly increased over the past three decades, surpassing the rise in the general population of overweight patients. Weight loss outcomes after bariatric surgery in patients suffering from extreme obesity are less favorable, with a higher incidence of weight regain. Variations of existing bariatric procedures have been proposed to address this issue. One such variation is adding a gastric band to limit the expansion of the newly created pouch. Limited data exist regarding the effectiveness of this procedure, called the banded one-anastomosis gastric bypass (BOAGB) procedure, compared to other bariatric procedures.

METHOD

In this retrospective study, we compared all patients who underwent the BOAGB procedure at the Bariatric Surgery Unit in our Medical Center with a postoperative follow-up of at least 1 year with patients who underwent a one-anastomosis gastric bypass (OAGB) or sleeve gastrectomy (SG) procedures. Data collected included demographics, comorbidities, surgical outcomes, complications, and postoperative quality-of-life assessments.

RESULTS

One hundred eleven patients were enlisted to our study during the relevant study period-24 patients underwent the BOAGB procedure, 43 underwent OAGB, and 44 underwent a SG. Lost to follow-up beyond 30 days was 9% (at 1-year post-surgery, we were able to establish contact with 101 patients). The pre-op BMI was significantly higher in the BOAGB group compared to the other procedures. Additionally, a higher prevalence of diabetes was observed in the BOAGB group. The duration of surgery was significantly longer for the BOAGB procedure. No significant differences were found in surgical complications. Overall, all procedures resulted in significant excess weight loss (EWL) or change in BMI, improvement in comorbidities, and improved quality of life postoperatively.

CONCLUSIONS

The BOAGB procedure, like OAGB and SG, demonstrated favorable weight loss outcomes and weight maintenance 1 year postoperatively without significant differences between the procedures. The BOAGB procedure is relatively new, with good bariatric outcomes and a favorable safety profile. Long-term study is needed to evaluate these various bariatric procedures' efficacy further.

Banded Versus Non-banded Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Standard bariatric surgeries include biliopancreatic diversion (BPD), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and adjustable gastric banding (AGB). Laparoscopic sleeve gastrectomy (LSG) is currently favored due to safety, efficacy, and shorter operation time. However, previous literature shows 75.6% weight regain post LSG. Introducing Laparoscopic band sleeve gastrectomy (LBSG) to maintain pouch size is proposed to improve outcomes and reduce weight regain. This study aims to compare the safety and efficacy of LSG vs. LBSG in obese patients. A comprehensive search strategy was executed to identify pertinent literature comparing LBSG and LSG in obese patients. Eligible studies underwent independent screening, and pertinent data were systematically extracted. The analysis employed pooled risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous variables, each accompanied by their respective 95% confidence intervals (CI). Our systematic review and meta-analysis included 15 studies encompassing 3929 patients. Regarding body mass index (BMI), at six, 12, and 24 months, no substantial differences were found between LBSG and LSG groups (p < 0.05). Still, at 36 months, LBSG exhibited significantly lower BMI than LSG (MD = -2.07 [-3.84, -0.29], p = 0.02). Excess Weight Loss (EWL) favored LBSG at 12, 24, and 36 months with MD of 3.30 [0.42, 6.18], 4.13 [1.44, 6.81], and 18.43 [9.44, 27.42], p = 0.02, 0.003, < 0.00001, respectively). Operative time did not significantly differ between the procedures (MD = 2.95, 95%CI [-0.06, 5.95], p = 0.05). Resolution of comorbidities, overall complications, post-operative bleeding, reflux, and early complications did not significantly differ between LBSG and LSG. However, LBSG showed higher post-operative regurgitation than LSG (RR = 2.38, 95%CI [1.25, 4.54], p = 0.008). LBSG showed a substantial decrease in BMI at three-year follow-up and higher EWL at one, two, and three years. However, LBSG procedures exhibited a higher incidence of post-operative regurgitation symptoms than LSG. No substantial differences were noted in BMI at six, 12, or 24 months, EWL at six months, operative time, bleeding, reflux, or overall complications.

First Global Report of Catastrophic Results Due to Internal Herniation of Roux Limb in the Space Between the Gastric Pouch and Band: a Series of 3 Cases of Banded Roux-en-Y Gastric Bypass (BRYGB)

BACKGROUND

Banded Roux-en-Y gastric bypass (BRYGB) is associated with complications known with the bypass along with specific complications related to the band. Roux-limb gangrene, due to herniation between the gastric pouch and band, however, has no mention in literature.

METHODS

We report this potentially fatal complication of BRYGB and its management in a series of 3 patients.

RESULTS

All 3 patients were women, 35-45 years, with a BRYGB (roux limb-150 cm, biliopancreatic limb-100 cm) using a MiniMizer or a Fobi ring with 2-point fixation to the gastric pouch 2 cm above the gastrojejunostomy. All patients presented 3-4 years post-BRYGB, with an average total body weight loss (TWL%) of 41.28%. To discuss video of a single case, a 35-year-old female presented with abdominal pain, hematemesis and signs of abdominal tenderness and guarding. X-Ray abdomen showed distended small bowel loops and CT-scan revealed ischemic small bowel loops with free fluid. Diagnostic laparoscopy showed alimentary/roux limb (AL) gangrene, from the gastrojejunostomy to the jejunojejunostomy. The entire AL had herniated between the gastric pouch and band which had formed an obstructive ring around the herniated bowel loop and led to compromise of blood supply and gangrene. Resection of gangrenous bowel with reversal of BRYGB was done.

CONCLUSION

Early diagnosis and timely management may save a patient from gangrene. It also raises questions: Is a 2-point fixation of the band to the gastric pouch insufficient? Does a longer roux limb make it prone to herniating in the space between the gastric pouch and band?

Banded versus non-banded sleeve gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic banded sleeve gastrectomy (LBSG) has been compared to laparoscopic sleeve gastrectomy (LSG) in terms of anthropometric results and postoperative complications, which are controversial. This systematic review and meta-analysis aimed to compare the safety and efficacy of LBSG and LSG.

METHODS

We performed a systematic review with meta-analysis according to preferred reporting items for systematic review and meta-analysis 2020 and assessing the methodological quality of systematic review 2 guidelines. We included studies that systematically searched electronic databases and compared LBSG with LSG conducted until August 10, 2021.

RESULTS

The literature search yielded 8 comparative studies. Seven hundred forty-three patients were included: 352 in the LBSG group and 391 in the LSG group. LBSG group allowed greater anthropometric parameters (body mass index [BMI] after 1 year (mean difference [MD] = -3.18; 95% CI [-5.45, -0.92], P = .006), %EWL after 1 year (MD = 8.02; 95% CI [1.22, 14.81], P = .02), and %EWL after 3 years (MD = 10.60; 95% CI [5.60, 15.69], P < .001) and similar results with LSG group in terms of operative time (MD = 1.23; 95% CI [-4.71, 7.17], P = .69), food intolerance (OR = 1.72; 95% CI [0.84, 3.49], P = .14), postoperative vomiting (OR = 2.10; 95% CI [0.69, 6.35], P = .19), and De novo GERD (OR = 0.65; 95% CI [0.34, 1.26], P = .2). Nevertheless, major postoperative complications did not differ between the 2 groups.

CONCLUSIONS

This systematic review and meta-analysis comparing LBSG and LSG concluded that banding sleeve gastrectomy (SG) may ensure a lower BMI and %EWL after 1 year of follow-up, and a significant reduction in %EWL after 3 years of follow-up. There is no evidence to support LBSG in vomiting, de novo GERD, food intolerance, or operative time.

Effect of Banded Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy on Diabetes Remission at 5 Years Among Patients With Obesity and Type 2 Diabetes: A Blinded Randomized Clinical Trial

OBJECTIVE

To determine whether silastic ring laparoscopic Roux-en-Y gastric bypass (SR-LRYGB) or laparoscopic sleeve gastrectomy (LSG) produces superior diabetes remission at 5 years.

RESEARCH DESIGN AND METHODS

In a single-center, double-blind trial, 114 adults with type 2 diabetes and BMI 35-65 kg/m2 were randomly assigned to SR-LRYGB or LSG (1:1; stratified by age-group, BMI group, ethnicity, diabetes duration, and insulin therapy) using a web-based service. Diabetes and other metabolic medications were adjusted according to a prespecified protocol. The primary outcome was diabetes remission assessed at 5 years, defined by HbA1c <6% (42 mmol/mol) without glucose-lowering medications. Secondary outcomes included changes in weight, cardiometabolic risk factors, quality of life, and adverse events.

RESULTS

Diabetes remission after SR-LRYGB versus LSG occurred in 25 (47%) of 53 vs. 18 (33%) of 55 patients (adjusted odds ratios 4.5 [95% CI 1.6, 15.5; P = 0.009] and 4.2 [1.3, 13.4; P = 0.015] in the intention-to-treat analysis). Percent body weight loss was greater after SR-LRYGB than after LSG (absolute difference 10.7%; 95% CI 7.3, 14.0; P < 0.001). Improvements in cardiometabolic risk factors were similar, but HDL cholesterol increased more after SR-LRYGB. Early and late complications were similar in both groups. General health and physical functioning improved after both types of surgery, with greater improvement in physical functioning after SR-LRYGB. People of Māori or Pacific ethnicity (26%) had lower incidence of diabetes remission than those of New Zealand European or other ethnicities (2 of 25 vs. 41 of 83; P < 0.001).

CONCLUSIONS

SR-LRYGB provided superior diabetes remission and weight loss compared with LSG at 5 years, with similar low risks of complications.

Comparison of Outcomes Between Banded and Non-banded Sleeve Gastrectomy: a Systematic Review and Meta-analysis

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric procedure performed worldwide. It accounts for more than 50% of primary bariatric surgeries performed each year. Recent long-term data has shown an alarming trend of weight recidivism. Some authors have proposed the concurrent use of a non-adjustable gastric band to decrease long-term sleeve failure.

OBJECTIVE

To compare the outcomes (weight loss) and safety (rate of complication and presence of upper GI symptoms) between SG and BSG.

METHODS

A systematic search with no language or time restrictions was performed to identify relevant observational studies and randomized controlled trials (RCT) evaluating people with morbid obesity undergoing SG or SGB for weight loss. An inverse-of-the-variance meta-analysis was performed by random effects model. Heterogeneity was assessed using Cochrane X² and I² analysis.

RESULTS

A total of 7 observational studies and 3 RCT were included in the final analysis. There were 911 participants pooled from observational studies and 194 from RCT. BSG showed a significant higher excess of weight loss (% EWL). The difference among groups was clinically relevant after the third year where the weighted mean difference (SMD) was 16.8 (CI 95% 12.45, 21.15, p < 0.0001), while at 5 years, a SMD of 25.59 (16.31, 34.87, p < 0.0001) was noticed. No differences related to overall complications were noticed. Upper GI symptoms were up to three times more frequent in the BSG group (OR 3.26. CI 95% 1.96, 5.42, p < 0.0001).

CONCLUSIONS

According to the results, BSG is superior to SG in weight loss at 5 years but is associated with a higher incidence of upper GI symptoms. However, these conclusions are based mainly on data obtained from observational studies. Further RCT are needed to evaluate the effect and safety of BSG.

Closed loop small bowel obstruction due to herniation through silastic ring after bariatric surgery

Bariatric surgery is an effective treatment for obesity and obesity-related complications. Weight regain after surgery plagues all methods of bariatric procedures including the minigastric bypass. The use of a 'silastic ring' around the gastric pouch has been shown to reduce weight regain. We present here a very rare complication of silastic ring use, in which a loop of small bowel had herniated through the ring and produced a closed loop small bowel obstruction. The patient was successfully treated with an emergency laparotomy to resect the silastic ring and release the herniated bowel. This case highlights the hernia risk that silastic rings pose and cautions careful consideration before their use.

The Benefits of Banded over Non-banded Roux-en-Y Gastric Bypass in Patients with Morbid Obesity: a Multi-center Study

Background

Roux-en-Y gastric bypass (RYGB) has proven to be an effective treatment for obesity with excellent long-term results, even though weight regain can occur. A method to improve the results of RYGB and minimize chance of weight regain is banded RYGB. Better sustained weight loss is also related to higher remission of comorbidities. The aim of this study was to evaluate the effect of banded and non-banded RYGB on long-term weight loss results and comorbidities.

Method

A retrospective comparative data study was performed. Patients who underwent a primary RYGB between July 2013 and December 2014 and followed a 5-year follow-up program in the Dutch Obesity Clinic were included. Comorbidities were assessed during screening and follow-up.

Results

The study included 375 patients with mean weight and body mass index (BMI) of 128.9 (± 21.2) kg and 44.50 (± 5.72) kg/m². Of this group, 184 patients underwent RYGB and 191 banded RYGB. During follow-up (3 months, 1–5 years) % Total Weight Loss (%TWL) was superior in the banded group (32.6% vs 27.6% at 5 years post-operative, p < 0.001). Complication rates in both groups were similar. Comorbidity improvement or remission did not significantly differ between the two groups (p = 0.14–1.00). After 5 years of follow-up, 79 patients (20.5%) were lost to follow-up.

Conclusion

Banded RYGB does show superior weight loss compared to non-banded RYGB. No difference in effect on comorbidity improvement or remission was observed. Since complication rates are similar, while weight loss is significantly greater, we recommend performing banded RYGB over non-banded RYGB.

Graphical abstract

Laparoscopic Banded One Anastomosis Gastric Bypass: A Single-Center Series

INTRODUCTION

Laparoscopic one anastomosis gastric bypass (LOAGB) is a relatively new procedure for the treatment of morbid obesity and related comorbidities. On average, this procedure results in good postoperative weight loss with a low complication rate. Recent publications suggest that dumping syndrome and weight regain might be reduced by placing a silicone ring over the gastric pouch during the procedure, so called laparoscopic banded one anastomosis gastric bypass (LBOAGB).

METHODS

86 patients undergoing LBOAGB between 2018 and 2020 were enrolled in this retrospective study. Hospital records were used to assess weight loss, comorbidity resolution, and any complications either in the short or medium term.

RESULTS

54 Female and 32 male patients were included with a mean age of 43 years (25-64), preoperative body mass index of 42 kg/m² (35-49), and preoperative weight of 114 kg (86-162). Thirty-four patients presented with type 2 diabetes (39.5%), 42 patients (49%) diagnosed with hypertension, 24 presented with OSAS (28%), and 21 (24%) hypercholesterolaemia patients were included. In total, 36 patients were diagnosed with multiple comorbidities. The operative data showed an average operative time of 48 minutes with 3.4% of patients suffering from early (minor) complications and 2.3% with a late (minor) complication. One patient required reoperation due to intra-abdominal bleeding. The median length of hospital stay was 2.5 days. Median follow-up was 18 months (5-36). In that period, no patient required ring removal or conversion to Roux-en-Y gastric bypass surgery. Food intolerance/vomiting was present in 1 patient (1.1%), bile reflux was present in 1 patient (1.1%), and no stomal ulcers were observed. Mean % excess weight loss at 12 and 24 months was 72% and 80%, respectively. Fifty-two out of 86 patients (60%) had a complete resolution of comorbidities. A CONUT score >2 (mild malnutrition) was found in 40% of patients, while a CONUT score 0-1 was found in 60% of patients.

CONCLUSION

LBOAGB shows promising results in terms of safety and efficacy in the short term. Further prospective studies will be required to evaluate the consistency of the results in the long term.

Quality of Life After Bariatric Surgery-a Systematic Review with Bayesian Network Meta-analysis

OBJECTIVE

Comprehensive analysis and comparison of HRQoL following different bariatric interventions through systematic review with network meta-analysis.

BACKGROUND

Different types of bariatric surgeries have been developed throughout the years. Apart from weight loss and comorbidities remission, improvement of health-related quality of life (HRQoL) is an important outcome of metabolic surgery.

METHODS

MEDLINE, EMBASE, and Scopus databases have been searched up to April 2020. Inclusion criteria to the analysis were (1) study with at least 2 arms comparing bariatric surgeries; (2) reporting of HRQoL with a validated tool; (3) follow-up period of 1, 2, 3, or 5 years. Network meta-analysis was conducted using Bayesian statistics. The primary outcome was HRQoL.

RESULTS

Forty-seven studies were included in the analysis involving 26,629 patients and 11 different surgeries such as sleeve gastrectomy (LSG), gastric bypass (LRYGB), one anastomosis gastric bypass (OAGB), and other. At 1 year, there was significant difference in HRQoL in favor of LSG, LRYGB, and OAG compared with lifestyle intervention (SMD: 0.44; 95% CrI 0.2 to 0.68 for LSG, SMD: 0.56; 95% CrI 0.31 to 0.8 for LRYGB; and SMD: 0.43; 95% CrI 0.06 to 0.8 for OAGB). At 5 years, LSG, LRYGB, and OAGB showed better HRQoL compared to control (SMD: 0.92; 95% CrI 0.58 to 1.26, SMD: 1.27; 95% CrI 0.94 to 1.61, and SMD: 1.01; 95% CrI 0.63 to 1.4, respectively).

CONCLUSIONS

LSG and LRYGB may lead to better HRQoL across most follow-up time points. Long-term analysis shows that bariatric intervention results in better HRQoL than non-surgical interventions.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.

RECENT FINDINGS

This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

Multiple concurrent complications of Roux-en-Y gastric bypass with MiniMizer gastric ring-alimentary limb intussusception through slipped ring into pouch, with remnant stomach internal herniation

Roux-en-Y gastric bypass (RYGB) is the second most common bariatric procedure performed in Australia, second to sleeve gastrectomy. Banding of pouches and anastomoses, via silastic bands or MiniMizer rings, have been used to assist in improving restriction. Though banded gastric bypasses are effective in weight loss, band migration, whether it be slippage or erosion, occurs in up to 7% of banded bariatric procedures. Jejunal intussusception and internal herniation are both individually known complications of RYGB. It is, however, rare to have all three phenomenon occur in a single patient. In this study, the authors present a report of a middle-aged lady, 2 years post-primary RYGB with MiniMizer gastric ring insertion presenting with all three complications.

Weight Loss and Vomiting 1 Year After Banded Versus Non-banded One Anastomosis Gastric Bypass: a Prospective Randomized Trial

BACKGROUND

The weight loss outcomes after banded one-anastomosis gastric bypass (OAGB) remain to be determined.

OBJECTIVE

To compare weight loss and vomiting 1 year after banded versus non-banded OAGB.

METHODS

This is a prospective, open-label, randomized study, which evaluated 33 individuals with morbid obesity, which underwent banded (16 individuals) and non-banded OAGB (17 individuals) and were followed up for 12 months. Weight loss (percentages of total weight loss-%TWL-and excess weight loss-%EWL) and occurrence of vomiting were assessed and compared before surgery and after 6 and 12 months.

RESULTS

At baseline, there were no differences between groups in regard to age, gender, and body mass index (BMI). At 6 and 12 months post-op, and the overall mean %TWL regardless of band use was 22.4 ± 7% and 29 ± 6.9%, respectively, and the overall average %EWL regardless of band use was 66.8 ± 22.9% and 86.3 ± 24%, respectively. %TWL did not differ between the banded and non-banded groups at 6 (21.8 ± 6.8% vs. 23.1 ± 7.4%; p = 0.7) and 12 months post-op (27.5 ± 6.6% vs. 30.4 ± 7.1%; p = 0.3), as well as %EWL at 6 (67 ± 22.9% vs. 67.6 ± 23.6%; p = 0.6) and 12 months post-op (83.5 ± 24.4% vs. 89 ± 24.1%; p = 0.4). The occurrence of vomiting did not significantly differ between banded and non-banded OAGB at 6 (12.5% vs. 11.8%; p = 0.9) and 12 months post-op (12.5% vs. 5.9%; p = 0.5).

CONCLUSION

OAGB led to an overall satisfactory weight loss after 1 year, regardless of band use. Banded OAGB did not lead to neither significantly higher weight loss nor more vomiting than non-banded OAGB 1 year after surgery.