2201 Innovative Endoscopic Management of a Bariatric Surgery Complication

Abstract

INTRODUCTION: Vertical Banded gastroplasty (VBG) is a purely restrictive bariatric surgery that was the predominant weight loss procedure in the 1980s. The following case describes a well-known complication of VBG that was managed with an innovative endoscopic technique. CASE DESCRIPTION/METHODS: A 56-year-old lady with a history of open VBG 18 years ago presented with several years of recurrent vomiting, heartburn, and excessive weight loss. An upper GI series revealed a large distend proximal gastric pouch above the mesh with severe stasis that produced a mass effect and resultant compression of the rest of the stomach. She was offered a conversion to Roux en y gastric bypass, however she declined. She was subsequently referred to a GI for further evaluation and potential endoscopic intervention. An Upper GI endoscopy was performed, which revealed mild esophagitis, evidence of vertical banded gastroplasty, and gastric pouch distention with copious amount of food debris. The lumen through the band was identified and was noted to be very narrowed and was not easily traversable with the upper endoscope. Therefore, a decision was made to perform an EUS guided gastro-gastrostomy with placement of a lumen opposing metal stent. The distal pouch was punctured under EUS guidance and a 15 × 10 mm AXIOS Stent was deployed adjacent to the previously placed band, creating a larger lumen for food content to pass. The stent was serially dilated to 18 mm using a through the scope (TTS) dilator. Contrast injected proximally was seen to flow freely from the gastric pouch into the antrum and the duodenum through the stent. Patient had an uneventful post-procedure course and was discharged the next day. She later reported significant improvement in reflux symptoms, gained 15 pounds, and was more than elated. DISCUSSION: VBG quickly gained popularity in the 1980s because it was the only bariatric surgery that did not have malabsorptive side effects. Over time, however, patients began experiencing post procedural nausea, vomiting, and heartburn from pouch dilatation, band erosion, staple line disruption, marginal ulceration, and is now rarely used as a bariatric surgical option. The versatility of endoscopic stents have made them useful in the management of many bariatric surgical complications, including fistulas, leaks, obstructions, strictures, and stenoses. To our knowledge, this was the first case of severely symptomatic pouch dilatation following VBG that was successfully managed endoscopically.