IBC Oxford University Oral Abstract 17 - Video abstract: lateral gastrectomy with greater curvature dissection as a standardized alternative to performing primary OAGB

Abstract Introduction A standardized approach to One Anastomosis Gastric Bypass (OAGB) has been recommended. Most authors describe a lesser curvature approach beginning with a perigastric dissection at 1–2 cm below the Crow's Foot of the incisura angularis followed by creation of restricted gastric pouch by deploying a linear staple line along the lateral border of a bougie until the angle of His is transected. This lesser curvature approach requires a retrogastric dissection to create optimal visualization prior to positioning the final staple cartridge at the angle of His. Patients who have had prior upper foregut surgery, reversal of a previous gastric bypass or placement of an adjustable gastric band can present with significant retro-gastric adhesions making operative dissection in this standardized technique difficult. Case Presentation We evaluated the feasibility of performing OAGB using a greater curvature dissection rather than a retrogastric lesser curve dissection in 2 patients who had each undergone two previous upper foregut operations. The first underwent prior placement and subsequent removal of an adjustable gastric band while the other had undergone reversal of an ineffective Roux Y gastric bypass. In each case the short gastric vessels of the greater curvature were divided allowing exposure of the left crus and release of any retrogastric adhesions and exposure of the stomach down to the level of the antrum. A 40 French bougie was positioned into the proximal antrum followed by transection of the antrum medial to the bougie. A 16–18 cm restricted gastric pouch was created by positioning a second staple line lateral to the bougie and applying multiple applications of a linear stapler until the angle of His was transected and the greater curvature lateral to the staple line removed. A 200 cm biliopancreatic limb was measured distal to the ligament of Treitz, and the one anastomosis gastric bypass was completed using a side-by-side gastrojejunal anastomosis as described by Carbajo. Each patient was discharged after a 2-night hospitalization. There were no readmissions or complications within 30 days. Each patient advanced to a regular diet within 21 days of the operation. Preoperative and post operative GERD quality of life assessments were compared and there was no significant GERD reported following creation of the OAGB. Conclusion Creation of a OAGB after multiple previous upper foregut operations can be done in a standardized fashion utilizing a greater curvature approach. The greater curvature approach requires resection of the greater curve of the stomach similar to that of a sleeve gastrectomy but allows for creation of a standardized and restricted gastric pouch of 16–18 cm over a 40 French bougie. Creation of a gastrojejunostomy utilizing a 200cm biliopancreatic limb is done in a manner identical to the typically utilized lesser curve approach. A standardized 16–18 cm OAGB can be created without the increased risk inherent with the lesser curvature retrogastric approach. This technique can be successfully utilized in patients expected to have significant retrogastric adhesions following previous upper foregut operations.