Banded Versus Nonbanded Sleeve Gastrectomy

A Randomized Controlled Trial With 3 Years of Follow-up

Jodok M. Fink, MD; Andrea Hetzenecker, MD; Gabriel Seifert, MD; Mira Runkel, MD; Claudia Laessle, MD; Stefan Fichtner-Feigl, MD; Goran Marjanovic, MD


Annals of Surgery. 2020;272(5):690-695. 

In This Article


This trial compared BSG to non-banded SG in 94 patients. It demonstrated better weight loss and increased quality of life for BSG. BSG did not affect complication rate, T2D remission, hypertension, and vitamin deficiencies. Frequency of regurgitation was significantly higher after BSG, whereas reflux symptoms occurred less frequently.

Weight loss was significantly better after BSG. Adjusted %EWL difference was 11.6%. Almost half (44%) of this difference can be attributed to lesser weight regain. This observation confirms multiple retrospective reports of better weight loss after BSG.[11–13] Very similar patterns could be observed in 2 meta-analyses comparing banded to nonbanded RYGB.[8,9] Our data provide corroborating evidence of weight-loss improvement when banding a standard bariatric procedure.

Although data is not fully conclusive, regurgitation has been reported as a negative consequence of BSG.[11–13] This trial affirms these findings. Clinically relevant regurgitation was considerably less frequent than previously described.[11,18] The authors attribute this to a learning curve of ring positioning and a larger ring circumference used. Most importantly, despite a certain amount of regurgitation, quality of life was better following BSG.

Previous examinations showed reduced frequency of reflux symptoms after BSG.[11,18] This trial supports these results at final follow-up. Possibly, the ring acts as a reflux barrier as suggested by Mason in vertical banded gastroplasty.[19,20] Follow-up gastroscopy cannot support a positive impact of the silicone ring. Furthermore, RSI values were not lower in BSG. Incidence of de novo reflux esophagitis was 21% to 30%, which is comparable with earlier reports.[21,22] Importantly, rate of de novo reflux esophagitis was not increased following BSG.

The trial was underpowered to compare diabetes remission. Among the low number of diabetics, BSG had no effect on resolution of T2D. Important mechanisms of diabetes remission rely on enteroendocrine stimulation.[23] This is not directly affected by the ring. However, a recent study demonstrated that for every 5% weight loss achieved, odds for diabetes remission increased by 54%.[6] Total weight-loss difference in the current trial was 6%.

Major late complication rates were within range reported by others.[24,25] Slippage was the most relevant ring-associated complication. In adjustable gastric banding (LAGB), either anterior or posterior gastric wall slips through the band.[26] In this case, slippage of the staple line through the ring resulted in a vertical ring position causing complete obstruction. As this was the first slippage described after BSG at that time, we chose to remove the ring as it is potentially the safest option.

Although some complications may commonly occur after BSG and LAGB, the principal concept of both interventions is different.[27] In LAGB, the implant is positioned around an intact stomach, applying constant pressure. In BSG, the implant is placed loosely around a preformed gastric sleeve. In this trial, ring diameter was approximately 2 times as wide as the bougie used for sleeve calibration. Constant pressure on the gastric wall is deliberately avoided. To date, we can only speculate on incidence of long-term complications of BSG. However, one of the main reasons widely abandoning LAGB was insufficient weight loss.[27] This is not likely to occur after BSG.[11,18]

This trial had several limitations. Despite a 3-year follow-up of 97%, a higher number of patients was lost in earlier follow-up visits. The study was underpowered to detect differences in metabolic outcomes such as T2D. Altogether, 4 patients in BSG but only one patient in SG had an RYGB at the last follow-up. This may have affected results of diabetes remission and weight loss. However, none of the RYGB patients had been diabetic preoperatively.

Retrospective data suggest greater weight loss in BSG compared to SG. Together with prospective data presented here, this ought to prompt the surgical community to inform patients of this procedural alternative. However, it has to be kept in mind that this is the first randomized controlled trial on BSG analyzing mid-term outcome in 94 patients.