Primary Gastric Bypass

The key concerns in performing banded gastric bypass as a primary procedure are band related complications.

The fear of erosions and even migrations derives from the initial series of banded bypass, where various materials were used, like e.g.mesh and rigid suture reinforced homemade rings with thick tied knots.

Initially rings with diameters of 5,0cm and 5,5cm were used, where there is now consensus that rings should be 6,5cm or larger.

Prefabricated and validated rings which are currently on the market, perfectly silastic material and a better understanding of how tight to tie the ring should be and where to place it, makes that these concerns are not necessarily justified anymore.

Erosion & Migration

Various authors have studied the erosion effect of the banded bypass.

Fobi [5] published a retrospective study of his 2.949 patients he performed a BRYGB on and found band erosion in 0,92% of his primary patients.

The erosions presented themselves in different ways as is described in Table 1. and were managed surgically in about half of the cases. 30% Was treated endoscopically and about 20% conservatively, by which the ring eroded spontaneously and was extruded via the stool.

Presenting symptoms of band erosion

Symptoms No. of Patients %
Weight Regain 18 37.50
Outlet Obstruction 17 36.42
Pain 9 18.75
Bleeding 7 14.58

Overall, the band erosion and removal rates seem to be between 0 and 2% in the long term.

Moreover, eroded bands are easily removed endoscopically, though surgery may be required. Similar numbers are confirmed by the meta analysis by Buchwald.

Both choice of material and size of the ring determine the level of erosion.

The ideal ring should have a little elasticity, which allows an easier food intake compared to a rigid band.

Stubbs [3] and Awad [1] advocate a size of 6,5cm in circumference in their 14 and 12 year follow up studies and advise that the ring should be loose around the stomach wall.

Requirement for ring removal related to ring size

Size of ring Number Rings removed
no ring 2 -
5.5 cm 66 10 (15%)
6.0 cm 181 11 (6%)
6.5 cm 92 2 (2%)
7.0 cm 1 0 (0%)

The exact location of the ring on the pouch plays a role as well.

Fobi [5] also demonstrated that placing the ring 1-2 cm proximal of the GJ anastomosis is more effective and gives less complications than placing the ring over the GJ anastomosis, as was initially done by Linner and Drew in 1985.

Other Complications

In numerous studies, all other major complications like small bowel obstruction, staple line leakage, etc. are equal for BRYGB and RYGB.

In some cases the complication rate seems even to be lower for BRYGB patients:

“ A significant proportion of RYGB patients experience dumping syndrome, whereas no instances of the syndrome were reported in the BRYGB patients in the included studies ”

Although a higher level of food intolerance has been described for the BRYGB patients, Awad [1] found in his 12-year follow up study, that there was no significant difference in quality of life compared to RYGB patients.

Lemmens [4] showed that, as long as the ring size is 6,5cm or larger, 18% of the patients appear to have difficulty eating bread or red meat, yet 95% of all banded patients indicate to be very satisfied with the procedure.

Conclusion

The low level of complications should not prevent surgeons from performing banded gastric bypass as a primary intervention.


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