Primary Surgery

Primary Banded Gastric Bypass

Although banded gastric bypass has been performed for various decades very few centers perform this surgical technique on a routine basis.

Lack of financial reimbursement is definitely a factor, but the fact that there are few
randomized controlled trials, yet plenty of retrospective data does not contribute to a
high acceptance level either.

However, in 2014 both Buchwald and Mahawar published insightful meta analyses of
8.707 and 2.254 patients respectively which help us to define the value of banded
gastric bypass.

Superior Results

Banded gastric bypass is an attractive bariatric procedure with superior weight loss outcomes, best demonstrated in super-obese patients.

“ The current meta-analysis and trend line comparisons suggest that B-RYGB’s intermediate term weight loss outcomes may be superior to those of RYGB. Whereas RYGB and bariatric surgery patients, on the whole, reach their BMI nadir approximately 2 years postsurgery and find that their weight loss decreases, this pattern was not seen in the current analysis of B-RYGB. ”

In O’Brien [2] et al’s systemic review and meta-analysis of 2006 of medium term weight loss after bariatric surgery it was observed that BRYGB “appeared to retain effectiveness better than RYGB, with the EWL significantly greater at 5 years for this group (74,7% Vs. 58,2%) (see fig. 1). NB This is an improvement of EWL of more than 28% remaining stable up until 10 years postop!

Years of Follow-up

% EWL

BRGB BPD/D RYGB LAGB

Fig. 1: Excess weight loss (%) in banded Roux-en-Y gastric bypass (B-RYGB) compared with Roux en-Y gastric bypass (RYGB), biliopancreatic diversion/duodenal switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB). RYGB, BPD/DS, and LAGB data, O’Brien et al.

O’Briens data are confirmed by the pooled mean excess weight loss at 5 years of 74,8% in the Buchwald analysis. The fact that the pooled mean excess weight loss in the 6-10 years postoperative follow up period remained at 72,3% indicates the longevity of the achieved EWL.

The 10 years follow up by Awad [1] reconfirms the same findings even over a 12 year period (see fig. 2), although the follow up rate at ten years becomes quite low!

Years

% EWL

banded non-banded

Fig. 2: Comparative EWL (%) up to 12 years. There is a significant difference from month 36 up to 10 years, Awad

Weight Regain

Banding the pouch also appears to have a positive effect in the prevention of weight regain.

Rasera [14] found in his 2015 prospective randomized study of 400 patients, that after 24 months the patients on the non banded group showed 10,5% of weight regain, compared to only 1% in the banded group.

Lemmens [4] also described in his series of 432 patients with a minimum follow up of 5 years that more than 45% of the BRYGB patients did not experience any weight loss at all vs. only 27% in the RYGB group. Of those patients who did gain weight at some point after their operation, the BRYGB patient invariably showed less regain than the RYGB patients (see fig. 3).

BMI weight regain

%

non-banded banded

Fig. 3: Less chance to regain weight for banded bypass patients (Dr. Lemmens, IFSO 2015]

“ In those rare cases of weight regain after BRYGB, the regain is also considerably less (8% of nadir weight low) compared to RYGB patients regaining weight (17-20% of nadir weight low). ”

Conclusion

After only 5 years, BRYGB achieves more than 25% higher EWL compared to RYGB and is associated with considerably less weight regain in primary surgery.

bandedgastricbypass.org

Super Morbidly Obese Patients

Where regular morbidly obese patients with BMI’s ranging 35-50 kg/m² tend to fail their bypasses in 20% of the cases, the super-obese patients have a long term failure rate of 40-60%. In contrast, in Magro’s study of banded patients, the failure rate of the superobese was 18,8% vs 11% for the morbidly obese group (Buchwald [10]). Capella and Fobi found a failure rate of their superobese patients of 7% after 5 years and Awad of 8% after 10 years!

More recently Schauer et al. [8] found a statistically significant difference of a 20% higher EWL for the super obese BRYGB patients after already 2 years in a matched cohort study comparing two groups of both 134 patients of banded vs non banded gastric bypass patients (see fig. 4).

Super-obese subgroup (BMI >50)

Mean

banded RYGB (n=105) non-banded RYGB (n=84)

Fig. 4: amongst the super-obese population in this study (78% of the banded bypass group and 63% of the non-banded bypass group), the mean preoperative body mass index (BMI) was similar in both the banded and non-banded bypass groups. Postoperatively, at a mean follow-up of almost 2 years, the decrease in BMI and %EWL were significantly greater in the banded-bypass group.

Similar results were found by Bessler in a double blinded trial with 90 patients, where a statistically significant difference was reached after 36 months, showing that the banded superobese patients reached 73% EWL and the regular RYGB patients got stuck at 58%. (Bessler [15]) (see fig. 5)

Percent Excess Weight Loss

Months

% EWL

banded non-banded

Fig. 5: Comparison of %EWL between banded and nonbanded patients during 36 months of follow-up.

Conclusion

There are good arguments available to state that the standard of care for super obese patients should be BRYGB. Superior results can be achieved within 2 years postop.


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