Background

The subject of our video presentation is a 59-year-old woman who underwent a vertical sleeve gastrectomy in 2012 in Arizona. She subsequently developed a stricture at the incisura angularis, which was initially managed with repeat endoscopic balloon dilations between 2015 and 2017. Due to persistent symptoms, she underwent laparoscopic gastrogastrostomy with anterior cruroplasty in 2017 in Oregon. She presented to us in 2021 with recurrent dysphagia, reflux, regurgitation, early satiety, persistent nausea, periodic emesis, and 10-pound unintentional weight loss over 6 months. Her BMI on presentation was 22.9. Single contrast upper GI and endoscopy revealed a stricture at the gastric anastomosis and a sliding hiatal hernia. We took her to the operating room to convert the gastric sleeve to Roux-en-Y gastric bypass and repair the hiatal hernia (see video). The patient also had a history of multiple urologic surgeries, most recently undergoing total cystectomy and continent urinary diversion with Indiana pouch in 2018. The presence of the Indiana pouch conduit at the umbilicus added complexity to this already difficult revisional procedure. The patient’s postoperative course was unremarkable. She was started on the ERAS pathway and was discharged within 48 hours. There were no complications within 30 days of surgery with significant improvement in symptoms on follow-up. Conversion to Roux-en-Y gastric bypass is the definitive treatment for stricture after VSG. A key to success in complex revisional bariatric surgery includes detailed preoperative planning and a methodical intraoperative approach paying particular attention to the definition of patient’s anatomy.