# Ring-Augmented Versus Non-Ring Augmented Sleeve Gastrectomy in Patients with BMI > 50 kg/m²: 3-Year Follow-up of a Randomized Controlled Trial

## TL;DR

A 3-year study found that ring-augmented sleeve gastrectomy (Ra-SG) led to better long-term weight loss and less weight regain compared to standard sleeve gastrectomy in severely obese patients.

## Contribution

This study is the first to compare Ra-SG and standard SG in patients with BMI >50 kg/m² over a 3-year period, showing Ra-SG improves weight-loss durability.

## Key findings

- Ra-SG resulted in significantly greater total weight loss (48.8% vs. 45.5%) at 36 months.
- Ra-SG had lower rates of clinically significant recurrent weight gain (5.9% vs. 16.3%).
- Pouch volumes were smaller in Ra-SG patients (160.1 mL vs. 194.2 mL).

## Abstract

Sleeve gastrectomy (SG) is effective but prone to late recurrent weight gain (RWG). Ring-augmented SG (Ra-SG) may preserve restriction and enhance long-term durability.

In this single-center, prospective, single-blind randomized trial, adults with a BMI > 50 kg/m² were randomized to SG or Ra-SG and followed for 36 months. The primary endpoint was percent total weight loss (%TWL) at 36 months. Secondary outcomes included RWG, gastric pouch volumetry, relapse of associated medical problems, complications, endoscopic findings, laboratory parameters, and patient-reported outcomes (SF-36, Suter).

Ra-SG produced significantly greater weight loss at 36 months (48.8 ± 8.3 vs. 45.5 ± 9.0%TWL; mean difference 3.25% points, 95% CI 0.86 to 5.63; p 0.008). Exploratory analyses showed lower rates of clinically significant RWG (≥ 30% regain: 5.9% vs. 16.3%; absolute risk difference − 10.4%, 95% CI − 19.6 to − 1.2; p = 0.033) and smaller pouch volumes (160.1 ± 8.9 vs. 194.2 ± 10.3 mL; p < 0.001). Perioperative complications were infrequent and comparable. At three years, the prevalence of endoscopic GERD was similar (17.3% vs. 19.6%). Food tolerance scores were consistently better after SG (all p < 0.05). HRQoL improved significantly in both groups, with no differences observed at 36 months. Two Ra-SG patients (1.8%) underwent ring removal.

Ra-SG enhanced weight-loss durability and lowered RWG compared to SG, with similar safety and GERD outcomes but decreased food tolerance at mid-term. Ra-SG may be considered in patients at higher risk of RWG, though multicenter studies with longer follow-up are needed to confirm these findings.

The online version contains supplementary material available at 10.1007/s11695-025-08431-1.

1. Ring-augmented Sleeve gastrectomy (Ra-SG) achieved greater %TWL at 3 years vs. Sleeve gastrectomy (+ 3.25% points, 95% CI 0.86–5.63; p = 0.008).

2. Recurrent weight gain (RWG) ≥ 30% was less frequent in Ra-SG (5.9% vs. 16.3%; absolute risk difference − 10.4%, 95% CI − 19.6 to − 1.2).

3. Safety and GERD profiles were similar between groups; ring removals were rare (1.8%).

4. Food tolerance was worse after Ra-SG at all follow-ups; counseling on eating behavior and adaptation is essential.

5. Health-Related Quality of Life (HRQoL) improved similarly in both groups; Ra-SG’s main value is weight-loss durability, not incremental HRQoL gains.

The online version contains supplementary material available at 10.1007/s11695-025-08431-1.