Gastric Bezoar after Vertical Banded Gastroplasty: A Case Report and Review of the Literature

doi:10.4236/ss.2011.25053

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Surgical Science, 2011, 2, 242-245

doi:10.4236/ss.2011.25053 Published Online July 2011 (http://www.SciRP.org/journal/ss)

Gastric Bezoar after Vertical Banded Gastroplasty: A Case

Report and Review of the Literature

Abdul S. Bangura, Stelin Johnson, Karen E. Gibbs

Division of Minimally Invasive and Bariatric Surgery, Staten Island University Hospital,

Staten Island, New York, USA

E-mail: [email protected]

Received February 18, 2011; revised April 25, 2011; accepted May 27, 2011

Abstract

Gastric bezoars are uncommon in the bariatric surgery population. Though popular in earlier decades, the

Vertical Banded Gastroplasty (VBG) is no longer a staple procedure in the United States. It has been sup-

planted by the Roux-en-Y gastric bypass (RYGBP) and the laparoscopic adjustable gastric band (LAGB) as

the most commonly performed bariatric procedures. However, there are many patients who have previously

undergone VBGs, and may present with associated complications. We present a case of a gastric obstruction

caused by a bezoar in a patient who had a VBG fifteen years prior to presentation.

Keywords: Vertical Banded Gastroplasty, Bariatric Surgery, Bezoar, Obstruction

1. Introduction

The VBG pioneered by Mason at the University of Iowa,

in the 1970’s was one of the most performed bariatric

operations in the 1980’s and early 1990’s [1]. It is a

purely restrictive procedure. Currently, it is less com-

monly performed in the United States as more effective

procedures have replaced it. Even so, the present day

bariatric surgeon must be aware of the VBG procedure

and the potential complications. The VBG features a

pouch based on the lesser curvature of the stomach and a

polypropelene mesh or silastic ring around the outlet of

the pouch. The combination of a small pouch and its

outlet restricted by the band leads to weight loss. How-

ever, this restriction may theoretically put the patient at

increased risk of bezoar formation and resultant pouch

outlet obstruction. Nonetheless, gastric bezoar following

VGB is very uncommon, with few reported cases in the

literature [3,4]. We present the diagnostic workup and

management of a patient who developed a gastric bezoar

fifteen years after a VBG.

2. Case Report

A 59-year-old female with a history of morbid obesity

(315 lbs, BMI 49.3) hypertension and diabetes mellitus,

underwent an open VBG in 1995. She reported a total

weight loss of approximately 100 lb s after the procedure,

but had regained some weight over the years. At the time

of presentation she weighed 225 lbs (BMI 35.2). She

presented with a five day history of epigastric pain and

intermittent, post prandial nausea and vomiting. Physical

exam was significant for mild epigastric tenderness, with

normal vital signs. Laboratory studies were normal on

presentation. An abdominal CT scan suggested a partial

gastric outlet obstruction with dilatation of the distal

esophagus and proximal stomach with collapse of the

distal segment (Figure 1). Endoscopic evaluation dem-

onstrated a narrow gastric outlet with mild gastritis and

an impacted phytobezoar (Figure 2). The bezoar was

successfully removed with a basket. The patient had an

uneventful post-procedure course and was subsequently

discharged with resolution of her acute symptoms. Of

note, the patient did report a history of difficulty with

certain foods which, over time, she had learned to avoid.

Figure 1. CT showing filling defect at level of pouch outlet.

A. S. BANGURA ET AL.243

Figure 2. EGD showing bezoar.

3. Discussion

Bezoars result from the accumulation of ingested mate-

rial in the form of masses or concretions in the gastroin-

testinal tract. They are rare, being found in less than 1%

of patients undergoing upper gastrointestinal endoscopy

[5]. Fox, et al. and Deitel, et al. have previously reported

gastric bezoar formation after vertical banded gastroplas-

ty [3,4]. More recently, bezoars have been reported in

bariatric patients after laparoscopic roux-en-y gastric

bypass and laparoscopic adjustable gastric band place-

ment [6-8]. Although rare, the purpose of this report is to

increase awareness of the problem, so clinicians will

have a high index of suspicion for its diagnosis when

bariatric patients present with obstructive symptoms. A

current literature review on bezoars is presen ted below:

The majority of bezoars occur in the stomach, but can

occur elsewhere in the GI tract.

Bezoars are classified according to their composition.

The major types are phytobezoars, trichobezoars, and

pharmacobezoars. Phytobezoars—composed of vegeta-

ble matter, are the most common type of bezoar. The

diospyrobezoar (persimmon fruit) accounts for the ma-

jority of cases. Lupini beans, used by holistic healers to

treat arthritic pain, have also formed a bezoar [9]. Tri-

chobezoars—composed of hair, usually occur in young

women with psychiatric disorders. Trichotillomania (hair

pulling) and trichophagia (hair eating) usually precede

trichobezoar formation. A few cases have been reported

in whom the gastric trichobezoar forms a long tail and

extends throughout the small bowel to the cecum. This

condition, known as the Rapunzel Syndrome, occurs

almost exclusively in young females [10-12]. Pharma-

cobezoars—composed of ingested medications, are in-

creasingly being recognized. Reported cases include ex-

tended release nifedipine, theophylline, enteric-coated

aspirin, sodium alginate, and sucralfate [13-17]. Bariatric

patients are advised to crush their medications before

ingestion to prevent this type of bezoar. Other Bezoars

composed of a variety of other substances have been

described. These include tissue paper, shellac, fungus,

styrofoam cups, cement, cardboard and vinyl gloves

[18-22].

Debakey observed in 1938 that most patients with be-

zoars had undergone gastric surgery, implying underly-

ing anatomic and functional abnormalities [23]. More

recent studies corroborate his observation, showing that

70% - 94% of patients have a history of gastric surgery

and 54% - 80% had undergone vagotomy and pyloro-

plasty [24,25]. The initial thought was that, delayed gas-

tric emptying is the most common functional abnormal-

ity found in patients with bezoars. However, some stud-

ies have found that many patients have normal or accel-

erated gastric emptying. In one series, gastric emptying

was studied in 10 patients who presented with bezoars up

to 20 years after gastric surgery and in operated patients

without bezoars [2 6]. There were no differences between

the two groups in gastric emptying of Technetium 99

m-labeled solids at 45, 75, and 105 minutes. This may

imply that the pathogenesis of bezoar formation is more

complex than initially thought and may involve other

factors such as alterations in the production of acid, pep-

sin, and mucus, and impairments in the grinding mecha-

nism and the interdigestive migrating motor complex

[27].

Most adults with phytobezoars are men between the

ages of 40 and 50 years, while trichobezoars are typically

seen in women in their 20’s [23]. Affected patients may

be asymptomatic for many years and develop symptoms

insidiously. Common complaints in clude abdominal pain,

nausea, vomiting (frothy vomiting is commonly observed

in bariatric patients with bezoars), early satiety, anorexia,

and weight loss [23]. It is difficult to distinguish symp-

toms attributable to bezoars from those caused by the

underlying condition (e.g., postgastrectomy syndromes,

gastroparesis). Up to 20% of patients continue to have

symptoms despite bezoar removal [28]. Gastrointestinal

bleeding is a common presentation since there is a high

association of gastric ulcers in patients with bezoars who

undergo surgery [23]. The ulcers may be due to peptic

ulcer disease or pressure necrosis. Although many be-

zoars become quite large, gastric outlet obstruction is an

uncommon presentation.

The physical examination is unremarkable in most pa-

tients with a gastric bezoar except for an occasional ab-

dominal mass or halitosis. Bezoars are usually discov-

ered as an incidental finding in a patient with nonspecific

symptoms. Abdominal radiograph with or without bar-

ium, abdominal ultrasound, or CT scan may show the

bezoar as a mass or a filling defect [29,30]. The gold

standard for diagnosis is an upper endoscopy as it pro-

vides for both diagnosis and therapeutic intervention.

A. S. BANGURA ET AL.

244

Therapy for bezoars should be tailored to the composi-

tion of the concretion and to the underlying pathophysi-

ologic process. Available treatment methods include

chemical dissolution, endoscopic and surgical removal.

Removal of the bezoar does not alleviate the underly-

ing problem. Preventive therapy should be implemented

to avoid recurrence, reported in 14% of patients [24].

Patients should be encouraged to drink lots of water, to

appropriately modify their diet (e.g., avoid persimmons

and stringy vegetables), to chew food carefully and pro-

perly (especially important for bariatric surgery patients)

and to seek psychiatric evaluation if needed (for trich-

obezoars). Treating an underlying motility problem may

be useful as a preventive measure in some patients.

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