Wayne S Lee, MD, Daniel Shouhed, MD, Miguel Burch, MD, FACS. Cedars Sinai Medical Center
Introduction: Vertical banded gastroplasty (VBG) was initially described in 1982 by Mason as a substitute to the gastric bypass. Over time, chronic complications became apparent – one of which is gastric outflow obstruction leading to dilation of the pouch, gastroesophageal reflux disease (GERD), esophageal dysmotility, and a pseudo-achalasia type picture. Hiatal hernias may compound the problem. Work up of complications after VBG include upper GI study to evaluate flow thru the anatomy, manometry if dysphagia is present, and endoscopy for assessment of pouch size, staple line visualization. One of the most critical steps in any VBG revision is clear identification of the prior vertical staple line, as our philosophy is to leave a healthy new staple line without crossing the former. If this step is not adhered, it may leave behind a triangle of ischemic tissue, leading to tissue necrosis and leaks.
Methods: Our video demonstrates our experience with VBG revision utilizing two approaches – first, conversion to laparoscopic roux en Y gastric bypass (RYGB), and second, reversal with endoscopic assisted transgastric stapled gastroplasty release.
Results: Case one: 61-year-old woman with a history of VBG who presented with significant GERD nonresponsive to proton pump inhibitors, nausea/vomiting, and weight regain due to maladaptive eating with a current body mass index of 40. Manometry demonstrated ineffective esophageal motility and poor bolus clearance with a non-relaxing high-pressure zone below the lower esophageal sphincter. The patient underwent a RYGB. Case two: 71-year-old woman with remote history of a VBG, chronic symptoms of significant esophageal dysmotility causing dysphagia. She also had protein malnutrition, vomiting, and GERD. Manometry demonstrated ineffective esophageal motility and poor esophageal bolus clearance on impedance. Due to the patient’s frail status and her main symptoms being related to the dysmotility, gastric outflow stenosis, and malnutrition, we recommended VBG reversal by performing a transgastric laparoscopic stapled gastroplasty takedown with endoscopic assistance. The patient had an uneventful post operative course – resuming a broad spectrum diet 2 weeks after surgery with resolution of her dysphagia and reported no heartburn.
Summary: Endoscopically assisted, transgastric stapled gastroplasty may be associated with a lower short-term complication rate thus allowing for the salvage of debilitated and compromised patients. Furthermore, this approach may be an option in patients who desire reversal without conversion to gastric bypass, are unable to tolerate an extensive dissection, nor able to heal multiple staple lines.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80572
Program Number: V093
Presentation Session: Bariatric Video Session
Presentation Type: Video
sages_adbutler_leaderboard