Laparoscopic adjustable gastric banding after previous Roux-en- Y gastric bypass

Abstract

Weight regain and inadequate weight loss after gastric bypass remain significant concerns, with potential effects on multiple quality measures. Poor restriction of oral intake owing to dilation of the small gastric pouch or the gastrojejunostomy is a potential cause of recidivism. Operative revision of the pouch or anastomosis can be technically difficult, carrying significant perioperative risk. Placement of a laparoscopic adjustable gastric band around the gastric pouch is an alternative for intervention in this patient population. We reviewed the pertinent data and describe our technique for laparoscopic placement of an adjustable gastric band after previous gastric bypass. The essential aspects of intraoperative anatomy, dissection, and decision making are covered, including the options for band fixation according to a particular patient’s history of previous gastric bypass and remnant tube gastrostomy. Methods The present case (and the corresponding video) was that of a 53-year-old morbidly obese woman with multiple comorbidities, including back pain, depression, and significant gastroesophageal reflux disease, with changes in Barrett’s esophagus after laparoscopic Nissen fundoplication. She had undergone laparoscopic Roux-en-Y gastric bypass with takedown of her previous fundoplication and decompression of her gastric remnant by tube gastrostomy. She had recovered well from that operation, with improvement of her gastroesophogeal reflux disease symptoms. However, she experienced poor (50%) excess weight loss during long-term follow-up, despite ongoing dietary evaluation and behavior modification counseling. Her principle complaint was an inadequate sense of restriction of oral intake. She completed an extensive workup, including a contrast swallow study and flexible upper endoscopy, which revealed a dilated gastrojejunostomy measuring approximately 3 cm in diameter. She subsequently underwent endoscopic suture plication of her gastrojejunostomy 29 months after her bypass, with minimal additional weight loss. After discussion of her options for additional intervention, she elected to undergo placement of an adjustable gastric band over her bypass. The pneumoperitoneum and our standard laparoscopic adjustable gastric band (LAGB), 5-port setup, were established. We then proceeded with careful dissection of the anterior small gastric pouch, Roux limb, and gastrojejunostomy away from the overlying liver, which was then elevated with a Nathanson retractor. A combination of ultrasonic, electrosurgical, and blunt dissection was used to identify the pars flaccida and angle of His. The pars flaccida was divided to reveal the right crus and distinguish it from the more laterally lying inferior vena cava. An opening for the retrogastric tunnel was created by dissecting along the medial aspect of the right crus. An esophageal dissector was then passed bluntly through the retrogastric tunnel and articulated to expose the tip at the angle of His. An AP standard LapBand (Allergan, Irvine, CA) was introduced into the patient’s abdomen and passed through the retrogastric tunnel using the esophageal dissector. The LapBand tubing and buckle were secured in the standard fashion. This patient’s gastric remnant remained fixed to the anterior abdominal wall with extensive adhesions from the previous tube gastrostomy, precluding safe use for band fixation. Therefore, we fashioned a piece of DermaMatrix (Musculoskeletal Transplant Foundation, Edison, NJ), measuring approximately 2 cm 8 cm, and secured it with permanent 2-0 Ethibond suture (Ethicon, Somerville, NJ) to