Laparoscopic Revision of Vertical Banded Gastroplasty to Sleeve Gastrectomy for Gastric Outlet Obstruction: Early Experience in Cohort of 18 Patients

Introduction: The long-term effectiveness of Vertical Banded Gastroplasty (VBG) is limited due to development of complications related to gastric outlet obstruction at the band site. Surgical reversal or conversion to Roux-en-Y gastric bypass has been the mainstay of treatment for complications. The purpose of this study was to assess outcomes of revising VBG to laparoscopic sleeve gastrectomy (LSG) in patients presenting with gastric outlet obstruction. Methods: We retrospectively reviewed 18 consecutive patients that underwent revision of VBG to LSG for gastric outlet obstruction, from 2008 to 2012, in an academic institution. Results: The mean age of the patients was 47 ± 11 years (89% females), with mean preoperative BMI of 36 ± 8 kg/m2. The mean length of time from the original VBG was 10 ± 7 years. Gastric outlet obstruction, diagnosed by EGD and UGI, was present in 100% (n=18). Intolerance to solid food was present in 39%, while 44% had reflux symptoms. The mean operative time was 187 ± 50 min. There was one conversion to open sleeve gastrectomy secondary to dense adhesions. There were two staple-line leaks (11%) requiring reoperation. There were no perioperative bleeds and no deaths. Symptom resolution was observed in 95% of patients. Postoperative BMI was 33 ± 6 kg/m2 at 15-month follow-up. Conclusion: Revision of VBG to LSG is a safe and feasible option for patients presenting with gastric outlet obstruction with low BMI. This procedure alleviates gastric outlet obstruction, while maintaining gastric restriction. Outlet stenosis at the neo-pylorus junction is amorbid complication following VBG, reported in approximately 10-20% of patients, leading to clinical manifestations of gastric outlet obstruction [3,7,8]. Usually a late complication, with an interval of about 5 years following the original surgery, patients can become quite symptomatic complaining of intractable vomiting, dysphagia or reflux [3,9]. Band slippage, occurring in 1-20% of patients, is another recognized etiology of gastric outlet obstruction [10]. As a general consequence of this obstruction, patients develop maladaptive eating strategies leading to significant weight re-gain [3]. Revisional bariatric surgery from the VBG to another bariatric procedure is becoming increasingly common, with the literature quoting rates between 10-65% [3,11,12]. Surgical reversal or conversion to Roux-en-Y gastric bypass (RYGB) has been the mainstay of treatment for complications. Due to its relative infancy, the Laparoscopic Sleeve Gastrectomy (LSG) is only starting to be used as a revisional option for failure. Initial studies have been shown it to be a feasible option with excess weight loss ranging between 16-64% [2,13,14]. The purpose of this study was to assess outcomes of revising VBG to laparoscopic sleeve gastrectomy (LSG) in patients presenting with gastric outlet obstruction.