Laparoscopic Revision of Banded Roux-En-Y Gastric Bypass: Pouch Resizing and Redo of Gastrojejunal Anastomosis for Ring Migration and Pouch Dilation

Abstract

Introduction: The Roux-en-Y gastric bypass (RYGB) is a surgical procedure to induce and maintain weight loss. It was first reported for the treatment of obesity in 1967.1 Since then, this surgery has undergone many modifications, such as the placement of a silastic ring around the gastroenterostomy site.2 This procedure, known as banded RYGB, was performed to restrict the rate of emptying of the pouch. Some patients develop serious ring-related complications, such as nausea, vomiting, regurgitation, and even malnutrition, requiring revision of their bariatric operation.3 The stenosis due to the ring migration leads to gastric pouch dilation and weight regain after distal obstruction resolution. A pouch resizing may be necessary to prevent obesity relapse. We present a video of a revisional laparoscopic surgery for the treatment of ring migration with gastric pouch dilation. Materials and Methods: A 48-year-old female with hypertension and type 2 diabetes underwent open-banded RYGB in 2007. The maximum weight was 119 kg (body mass index [BMI] = 44 kg/m2). The patient remained with stable weight until 2012. After 5 years of surgery, the patient weighed 62.1 kg (BMI = 23 kg/m2) with complete resolution of hypertension and diabetes. However, the patient started presenting gastroesophageal reflux symptoms, postprandial vomiting, and progressive weight loss. Seven years after surgery, the patient weighed 55 kg (BMI = 20.7 kg/m2). The patient was subjected to investigation. Endoscopy revealed Los Angeles grade C esophagitis and stenosis of the gastrojejunal anastomosis, upper gastrointestinal contrast study demonstrated ring migration, and computed tomography showed pouch volumetry of 110 mL. The patient underwent multiple upper endoscopies with dilations without substantive relief of symptoms. Laparoscopic approach was performed with gastrojejunostomy resection along with the ring, pouch resizing, and redo of gastrojejunal anastomosis within a 210 minutes procedure. Results: The postoperative period was uneventful. The patient started with fasting at postoperative day 1, presented good liquid diet acceptance, and had hospital discharged 4 days after surgery. No early complication was observed. After 2 years, the patient is without gastroesophageal reflux and no weight regain. Conclusion: Ring migration along with pouch dilation after banded RYGB can be safely managed through laparoscopic gastrojejunostomy resection and pouch resizing with immediate and long-term symptomatic improvement. This video was presented at the IFSO Congress 2014 in Montreal, Canada. No competing financial interests exist. Runtime of video: 4 mins 58 secs