Vertical-banded Gastroplasty to Roux-en-Y Gastric Bypass with Remnant Gastrectomy

This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures.

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This Month’s Technique: How to Convert an Adjustable Gastric Band Procedure to a Roux-en-Y Gastric Bypass

Vertical-banded Gastroplasty to Roux-en-Y Gastric Bypass with Remnant Gastrectomy

This Month’s Featured Expert: Kelvin Higa, MD, FACS, Clinical Professor of Surgery, University of California, San Francisco, Fresno, California, and Director, Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California

Bariatric Times. 2013;10(5):8–9.

Introduction
The vertical-banded gastroplasty (VBG) is of historic importance.1 Its development was one of observational science attempting to purely “restrict” caloric intake and was highly effective in the short run. Less technically challenging and safer than the early gastric bypass, its popularity reigned in the late 1980s. Unfortunately, this operation failed to achieve long-term weight maintenance due to lack of satiety; many patients changed their eating habits to include more easily tolerated liquid calories and avoided protein food sources for fear of gastroesophageal reflux disease (GERD) and regurgitation. Nondivided staple lines were prone to breakdown and the banded outflow tract was associated with late-onset stenosis, not amenable to endoscopic dilation.

Although not formally retired, few centers are still performing this operation. Because of its former popularity, many patients are now seeking help for weight recidivism, inadequate weight loss, GERD, chronic vomiting, pain, or a combination of the above. Fortunately, conversion to gastric bypass has been very successful in correcting most of the complications of this procedure, adding significantly to the patient’s quality of life. Although reports of conversion to adjustable gastric banding and vertical sleeve gastrectomy have been disappointing, results of conversion to gastric bypass are nearly as good as a primary operation. However, overall operative risks are significantly higher.[2–5]

Here, I describe my technical pearls for conversion of VGB to RYGB. This can be done open, but it is preferable to refer the patient to a center that can perform this operation laparoscopically, which should be the standard approach. It is of interest how several groups have described this approach independent of collaboration.[6,7] This approach is not at all intuitive, but after trying many other methods, I have found this is the safest and most effective means of conversion, without compromise to the gastric pouch construction common to re-operative surgery.

It is irrelevant whether the vertical staple line has broken down or if the band used is silastic or marlex. In every case, the pouch created is too large by today’s standards, so by definition, a new pouch must be created within the confines of the previous pouch. Thoughts of leaving behind previous staple lines and prosthetic material hinder one’s ability to accurately define the residual anatomy and to preserve the vascular supply to the new pouch, often leading to increased risk of leaks or compromising long-term results.

Surgical Technique
As most VGB procedures have been done through midline incisions, it is prudent to place the first trocar laterally, in anticipation of taking down the omental adhesions to the incision. Once these are freed, other trocars can be placed appropriate to the particular method of gastric bypass of which the surgeon is most comfortable. For revision surgery, it is important to consider a manual or hand-sutured anastomosis because of the discrepancy of thickness of scar and other tissues encountered.

There is usually an intense reaction at the site of the prosthesis to the undersurface of the left lobe of the liver. It is more intense with marlex bands; less so with silastic. In the past, some surgeons have tried to interpose omentum at this level, making visualization even more difficult. Staying in the correct plane of tissue to avoid unnecessary bleeding from the liver or serosal injury to the stomach is key to a successful dissection. A most important landmark is the caudate lobe of the liver, which, once identified, is the pathway to the lesser omentum and then, the right crus of the diaphragm. In all cases, the hiatus must be identified and the esophagus mobilized in order to correctly identify the esophagogastric (EG) junction and delineate the vertical staple line. Fortunately, there will be a significant hiatal hernia almost always present, which helps, as this will be virgin territory—no adhesions.

After the hiatus has been dissected (Figure 1), the operation is straightforward. The stomach is transected below the previous staple lines and prosthesis (Figure 2). (There is no reason to preserve the fundus; attempts to do so will compromise formation of the gastric pouch.) The short gastric vessels are taken down (Figure 3) and the proximal stomach is easily mobilized away from the pancreas and splenic vessels (Figure 3). Alternatively, the short gastric vessels can be approached medially—at times safer, with less potential injury to the splenic hilum or pancreas (Figure 4). At this time, the exposure is much the same as with a standard sleeve gastrectomy. As the greater curve is mobilized, the lesser curve vessels can be mobilized to a point proximal to the prosthesis (Figure 5), 3 to 4cm distal to the EG junction. This will define the inferior aspect of the pouch (Figure 6).

The vertical staple line is invariably hidden by gastro-gastric adhesions, imbricating the “true” staple line deep within the gastric tissue (Figure 7). It is important to open this plane so as not to include too much thicknesses of stomach in the new vertical staple line. If the gastric pouch is huge, this is not as big an issue as when it appears the stomach to be small. In most cases, the true staple line is 1 to 2cm deeper than one thinks on visual inspection alone.

As the pouch is now created inside the previous pouch, the resulting specimen will include all the previous staple lines as well as the prosthesis. The gastric bypass and gastrojejunostomy (GJ) anastomosis can now be performed in a standard fashion (Figure 8).

This method for conversion of the VBG to the gastric bypass allows for precise formation of the gastric pouch, without compromise to its size, orientation, blood supply, or innervation. One would expect, then, exactly the same results in a given patient population as a primary gastric bypass. These results are unusual in the world of re-operative surgery and perhaps, this is the only conversion where one can observe such results.

References
1.    Mason EE. Vertical banded gastroplasty for obesity. Arch Surg. 1982;117(5):701–706.
2.    Vasas P, Dillemans B, Van Cauwenberge S, De Visschere M, Vercauteren C. Short- and long-term outcomes of vertical banded gastroplasty converted to Roux-en-Y gastric bypass. Obes Surg. 2013;23(2):241–248.
3.    Thill V, Khorassani R, Ngongang C, et al. Laparoscopic gastric banding as revisional procedure to failed vertical gastroplasty. Obes Surg. 2009;19(11):1477–480.
4.    Foletto M, Prevedello L, Bernante P, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis. 2010;6(2):146–151.
5.    Suter M, Ralea S, Millo P, et al. Laparoscopic Roux-en-Y gastric bypass after failed vertical banded gastroplasty: a multicenter experience with 203 patients. Obes Surg. 2012;22(10):1554–1561.
6.    Gagné DJ, Dovec E, Urbandt JE. Laparoscopic revision of vertical banded gastroplasty to Roux-en-Y gastric bypass: outcomes of 105 patients. Surg Obes Relat Dis. 2011;7(4):493–499.
7.    Cadière GB, Himpens J, Bazi M, et al. Are laparoscopic gastric bypass after gastroplasty and primary laparoscopic gastric bypass similar in terms of results? Obes Surg. 2011;21(6):692–698.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery