John Primomo, MD, FACS, FASMBS1, Tanyaradzwa Kajese, MD2, Garth Davis, MD, FACS, FASMBS1, Robert Davis, MD, FACS, FASMBS1, Shinil Shah, DO2. 1The University of Texas Health Science Center at Houston, The Davis Clinic, 2The University of Texas Health Science Center at Houston
The Vertical Banded gastroplasty (VBG) was a completely restrictive alternative to the Roux-En-Y gastric bypass (RYGB). It involved a gastric pouch formed from a non-divided staple line with a distal restrictive silastic band. Unfortunately, up to 40-60% of patients that underwent this operation developed chronic dysphagia from an obstructing silastic band placed at the distal end of the gastric pouch. Many of these patients benefit from conversion of their VBG to a RYGB to address both their morbid obesity and gastric outlet obstruction.
We present a 47 year old female with a BMI of 48 and past surgical history of a VBG in 1999. She presented with persistent dysphagia and weight regain for several months. An upper GI contrast study confirmed VBG anatomy with concomitant gastric outlet obstruction at the silastic band site. Esophagogastroduodenoscopy confirmed VBG anatomy with a stricture at the silastic band site as well as an intact staple line. The decision was made to pursue a revision to a RYGB.
Gastrohepatic adhesions were approached in a medial fashion for clearer identification of the adhesive plane. Adhesions were taken down in a medial to anterolateral fashion. With full gastrohepatic adhesiolysis performed, attention was turned to identification of the vertical staple line of the VBG. The overlying plication was taken down to ensure that future staple loads could be fired across healthy gastric tissue. Short gastrics were then divided in preparation for the future partial gastrectomy. This ensures that the gastric remnant staple line is fired across well vascularized gastric tissue. The silastic band was cut and retrieved. The gastric pouch was formed in a perigastric fashion along a 34 French bougie with the prior VBG staple line pulled laterally. The ligament of Treitz was identified, and the jejunum and mesentery were transected 20cm distally. The jejunojejunostomy was created in a linear, hand sewn fashion with closure of the mesenteric defect. A gastrotomy and roux limb enterotomy were made. The gastrojejunostomy was then created using a linear, hand sewn technique. Following completion of this anastomosis, a leak test was carried out.
Revision of a VBG to a RYGB requires a full adhesiolysis for clear identification of the VBG anatomy. Addition of a partial gastrectomy affords that the gastric remnant staple line is across well vascularized tissue. Conversion to a RYGB treats both the dysphagia and weight regain associated with the vertical banded gastroplasty.