Silastic ring vertical gastric bypass:: Evolution of an open surgical technique, and review of 1,588 cases

Background: Silastic ring vertical gastric bypass (SRVGBP) has evolved from a stapled (SSRVGBP) to a transected (TSRVGBP), and finally to a transected pouch with jejunal interposition (TSRVGBP with J-I). The creation of the gastroenterostomy evolved from a hand-sewn to a stapled and finally to a combined stapled and hand-sewn anastomosis. The circumference of the ring was increased from 5.5 to 6.0 cm. We address the effect of these modifications on surgical outcome. Method: The records of 1,588 consecutive patients (mean BMI of 44.5) since 1990 who had a SRVGBP were indentified from a prospective data-base of all patients undergoing bariatric operations. 205 patients with a prior bariatric operation were excluded from the review, leaving 1,383 patients who had a primary SRVGBP. Results: In the 193 SRVGBP patients, there was 1 gastric leak (0.5%) and 64 gastrogastric fistulas (33.2%). In the 165 TSRVGBP patients, there were 4 gastric leaks (2.4%) and 14 gastrogastric fistulas (8.5%). In the 1,025 patients with TSRVGBP with JI, there were 8 gastric leaks (0.8%) and no gastro-gastric fistulas. In the TSRVGBP with J-I, 367 patients had a hand-sewn, 16 a stapled, and 642 a combined stapled and hand-sewn anastomosis. Stricture rate was 3.8%, 31 %, and 2.6% respectively. There were 7 ring migrations (0.7%), all in the totally hand-sewn group. Ring removal was necessary in 20 (5%) with a 5.5-cm and 4 (0.74%) with a 6.0-cm ring. Conclusion: TSRVGBP with J-I with a combined stapled and hand-sewn gastrojejunal anastomosis using a 6.0-cm ring decreased the incidence of complications, and is our current technique.