Banded Sleeve Gastrectomy Versus Banded Ring Gastric Bypass in Morbidly Obese Patients
Banded Sleeve Gastrectomy Versus Banded Ring Gastric Bypass in Morbidly Obese Patients
Obesity is a multifactorial disease that affects millions of people worldwide. It is the main
 independent risk factor for developing type 2 diabetes mellitus (T2DM). Most patients with
 T2DM and glucose intolerance (GI) are overweight, a condition known as diabesity. In patients
 with the most severe form of obesity, i.e., morbid obesity, the likelihood of developing
 diseases associated with obesity is increased.

 The investigators currently know that bariatric surgery provides sustained weight loss and
 well-documented remission of T2DM. Patients who undergo bariatric surgery show long-term
 reduced mortality from coronary artery disease, cancer and diabetes; 136 lives are saved per
 10,000 surgical procedures performed. Bariatric surgery is a relatively safe procedure that
 is becoming increasingly well-accepted; in 2007, approximately 170,000 bariatric procedures
 were performed in the USA. Currently, bariatric surgery is the most effective choice of
 treatment of morbidly obese patients with diabetes.

 The surgical procedures that are currently performed to treat morbid obesity are divided into
 two main groups: gastric restrictive procedures and combination procedures; the latter
 combine gastric restriction and malabsorption. The roux-en-Y gastric bypass (RYGB) is the
 combination procedure most frequently performed, whereas sleeve gastrectomy (SG) is an
 emerging restrictive procedure. SG can be performed as the first of a two-stage operation in
 patients at high risk of death, or as a definitive surgical procedure. It has shown good
 results with regard to weight loss and glycemic control in various studies. The potential
 advantages of SG include lower probability of vitamin and mineral deficiencies because this
 procedure has no malabsorptive component; access to the entire intestinal tract; no need for
 a subcutaneous access port or adjustments; absence of dumping syndrome and lower probability
 of intestinal obstruction. In addition, SG can be performed in patients who have inflammatory
 bowel disease or who have undergone bowel surgery, and it can be easily converted into RYGB.
 Both SG and RYGB can be performed with or without the placement of a Silastic® ring.

 The metabolic control achieved with bariatric procedures has been demonstrated and reproduced
 in various medical centers worldwide. Metabolic control can be achieved with gastric
 restrictive procedures such as vertical banded gastroplasty, adjustable gastric banding and,
 more recently, SG. However, it has been shown that glucose homeostasis is affected by various
 intestinal mechanisms observed exclusively in procedures that include a malabsorptive
 element, such as RYGB.

 A systematic review of 22,094 cases of morbidly obese patients submitted to bariatric surgery
 has shown that resolution of T2DM was achieved in 76.8% of the cases, improvement being
 achieved in 86% of cases. Among the criteria used to diagnose metabolic syndrome, fasting
 glucose levels are the first to return to normal in patients submitted to Silastic® ring
 gastric bypass (SRGB), a modification of the traditional RYGB which consists in adding a
 Silastic® ring to the gastric bypass operation. Normoglycemia after bariatric procedures, as
 well as diabesity itself, is multifactorial. Normoglycemia is observed as a result of dietary
 control, decreased plasma levels of ghrelin, weight loss and reduction of body fat, as well
 as of the release of gastrointestinal hormones that interfere with the function of pancreatic
 β cells (incretins).

 The main purpose of this study was to compare the weight loss of morbidly obese patients
 submitted to either a Silastic® ring sleeve gastrectomy (SRSG) or an SRGB, as well as to
 compare the effects of both procedures on glucose homeostasis in morbidly obese patients.
Inclusion Criteria:

 -  female patients aged 20-60 years

 -  BMI 40-45 (inclusive)

 -  agreed on giving written informed consent

 Exclusion Criteria:

 -  secondary obesity

 -  alcohol or drug use

 -  severe psychiatric disorder

 -  binge-eating of sweets

 -  previous stomach or bowel surgery