Band Over Bypass= BOB (as a revision)

At our institution, we frequently offer the adjustable gastric band as a surgical option for failed weight loss after RYGB. It is a technically simpler and safer operation to perform compared to other revision procedures and offers reasonable weight loss. The adjustable band is placed around the proximal gastric pouch and above the gastrojejunostomy. The remainder of the RYGB is left in-situ. O’Brien, et al., and Kyzer, et al., originally described converting any failed bariatric procedure (including gastric bypass) to the Lap-Band system.[14,15] Both series reported good weight reduction; however, subgroup analysis for failed RYGB was not provided.

A previous report from our own institution looked specifically at the use of adjustable gastric banding as a revision procedure for failed RYGB in eight patients.[16] Mean BMI prior to revision was 44.0±4.5Kg/m2. Patients had an average of four band adjustments over one year. Mean EWL was 38.1±10.4 percent at 12 months and 44.0±36.3 percent at 24 months. Another more recent report from NYU Medical Center revealed a mean 6.3Kg/m2 BMI decrease and approximately 20.8±16.9-percent EWL at 12 months in 11 failed RYGB patients.[17] Both series had minimal complications (mostly port-related).
Key technical points in placing the adjustable band on the upper pou*****lude the use of upper endoscopy to verify that the band is placed around the gastric pouch and not the esophagus, making sure that the band is at least 1cm proximal to the gastrojejunostomy, and using the fundus and the anterior wall of the bypassed stomach to plicate (with permanent sutures) above and below the band to ensure adequate anterior fixation. Sometimes, the gastric pouch alone is large enough to be used for the fundoplication.