Roux-En-Y gastric bypass on vertical banded gastroplasty via laparoscopic approach: surgical technique and outcome

Background: Roux-en-Y Gastric Bypass (RYGB) is one of the most widely performed bariatric operations, but its main disadvantage is that the gastric remnant,duodenum and biliary tree cannot be investigated during the follow-up by endoscopy or X-ray. Since 2002 a laparotomic modified technique was developed, the Roux-en-Y Gastric Bypass on Vertical Banded Gastroplasty (RYGB-on-VBG), which leaves a small outlet between the gastric pouch and the excluded stomach, allowing the passage of an endoscope. We report the outcome of this surgical technique performed laparoscopically in our series of patients. Methods: 40 consecutive morbid obese patients underwent laparoscopic RYGB-on-VBG since March 2008. Mean age was 42±9 years. Mean preoperative BMI was 44.3±4.6, mean weight 120±19 Kg. Comorbidities included hypertension in 19 patient (47%), type 2 diabetes mellitus in 10 patients (25%), all in pharmachological treatment, and OSAS in 5 patients. Surgical technique: the gastric pouch is created first, doing a gastric window at 9 cm from the esophagogastric junction with a CEEA stapler, on the guide of an endoluminal 32-Ch bougie. The stomach is then sectioned with endoGIA from the gastric window to the angle of His, creating therefore a gastric pouch with a small gastroplasty outlet, that is encircled with a Gore-Tex® band. The gastric bypass is then created, sectioning the jejunum and doing the gastrojejunostomy at 30 cm from the Treitz, and the jejunojejunostomy 150 cm more distad. Mean operating time was 240 minutes (360–150). A postoperative Gastrografin ® swallow showed that the main transit was through the gastrojejunostomy. Results: Mean BMI decreased from 44.3±4.6 to 35.8±4.1 after 6 months, to 34±4.5 after 12 months and to 30.5±3.5 after 18 months. %EWL was 42±11.7 after 6 months, 54.2±22.6 after 12 months, 62.7±23.4 after 18 months. At 1 year follow-up all diabetic patients stopped or reduced the antidiabetic treatment, 13 patients (68%) recovered completely from hypertension and 4 patients (80%) from OSAS. A gastroscopy was done after 1 year in the first 14 patients, showing that the possibility to access the distal stomach remained unchanged. Early postoperative complications included a gastrointestinal bleeding in 2 patients: in both cases a gastroscopy accessed the distal stomach, showing in one case a gastritis and in the other a hemorrhage from the jejuno-jejunostomy, that was treated endoscopically with clips. No long term complications were observed, except one patient who died from acute myocardial infarction 6 months after the operation. Conclusions: In our series the outcome and complications were comparable with other gastric bypass procedures. We may therefore suggest the adoption of this modified technique, that has the advantage of allowing the investigation of the distal stomach in case of bleeding or malignancy, as a reliable and laparoscopically feasible alternative to the traditional RYGB.