How to Place and Measure a Preanastomotic Ring

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This Month’s Technique: How to Place and Measure a Preanastomotic Ring

This Month’s Featured Expert: MAL Fobi, MD, FASMBS, FACS, FACN, FICS, Medical Director, Center for Surgical Treatment of Obesity, Saint Mary Medical Center, Long Beach, California, and Medical Director, Tri City Bariatric Program, Hawaiian Gardens, California

Bariatric Times. 2012;9(12):8–9

Funding: There was no funding for the preparation of this manuscript.

Disclosures: The GaBP Ring™ is approved for use in Europe, but is still an investigative device in the USA. FDA clinical trials are ongoing. Dr. Fobi has ownership interest in the GaBP Ring Device.

Introduction
Placing a preanastomotic ring in the gastric bypass enhances the restrictive component of the gastric bypass operation for obesity.[1]

A fixed pre-anastomotic ring placed at least 1cm above the gastroenterostomy site of the gastric bypass not only creates a fixed non dilatable stoma, but also results in a smaller, less dilatable pouch and minimizes the formation of a neo gastric reservoir.[2]
A preanastomotic ring results in more weight loss in more patients and the weight loss is maintained over a longer period of time than with the nonbanded gastric bypass.[3]

Currently, there is only one prefabricated device, the GaBP Ring™ (Bariatec Corporation, Palos Verdes Peninsula, California), made for use as a preanastomotic ring (Figure 1). It is available for use in Europe and internationally with a CE-Mark but is still under United States Food and Drug Administration (FDA) investigative device exemption evaluation. An adjustable ring is not recommended because there are other mechanisms in addition to the restriction that make a gastric bypass operation effective.
The GaBP Ring device comes in four sizes 6.0, 6.5, 7,0 and 7.5cm. The recommended size for women is 6.0cm, and 6.5cm is recommended for men. The 7.0 and 7.5cm sizes are recommended for revision operations and for use in banded sleeve gastrectomy operations.

Surgical Technique
Step 1. Create vertical gastric pouch. A vertical lesser curvature gastric pouch 5 to 6cm long is created (Figure 2).

Step 2. Introduce the GaBP Ring into the peritoneal cavity. The GaBP Ring is inserted into the peritoneal cavity and a perigastric channel is made through the lesser omentum 2 to 3cmm above the cut edge of the pouch (Figure 3).

Step 3. Guide and pull the introducer through the lesser omentum. The GaBP Ring is then passed through the perigastric channel using the introducer (Figure 4).

Step 4. Separate the GaBP Ring. The introducer and the latch are separated from the GaBP Ring (Figure 5).

Step 5. Lock the GaBP Ring. The male end is inserted into the female end until it clicks to lock the GaBP Ring (Figure 6a and Figure 6b).

Step 6. Place an absorbable suture around the ring. An absorbable suture is placed around the GaBP Ring at the antimesenteric border to prevent slippage (Figure 7a and Figure 7b). A capsule forms around the GaBP Ring within three weeks. The gastroenterostomy is then performed either hand sewn or using a staple device or a combination of both.

Conclusion
A preanastomotic ring in the gastric bypass controls both the pouch and stoma size, thus enhancing the restrictive component of the gastric bypass operation for obesity.

References
1.    Fobi MAL. Placement of the GaBP Ring system in the Banded gastric bypass operation. Obes Surg. 2005;8:1196–1201.
2.    Fobi. MAL ww.bariatec.com.
3.    O’Brien PE, McPhail T, Chaston TB et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006; 16:1032-1040.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery