Background

Patient is a 75-year-old female with past medical history of gastroesophageal reflux disease and obesity, with a remote history of a vertical banded gastroplasty (VBG) with Marlex mesh complicated with worsening reflux and symptomatic gastric outlet obstruction at the level of the band. Attempt was made to erode the Marlex mesh with an endoscopic stent, yet this was unsuccessful likely due to the fact that the Marlex mesh is too pliable. Upper gastrointestinal series revealed esophageal dilation and delayed passage of contrast at the level of the band. Esophagogastroduodenoscopy revealed severe esophagitis, mid gastric body stricture from the band, and retained food and bile in the upper gastric pouch. Additionally, she had a small gastrogastric fistula through the previous VBG staple line. Two kissing stents were placedan Axios stent was placed through the gastrogastric fistula to widen it, and an EndoMax stent was placed across the gastric outlet. The rationale of this was to apply more radial pressure on the gastric septum to allow for erosion of the Marlex mesh, however, the mesh still not eroded. We then decided to place a vessel loop around the gastric septum to function as a cutting seton (Endoseton) by creating further ischemia of tissue and allowing further mesh erosion. This video describes the steps for placement of the vessel loop around the gastric septum. As a result of this procedure the gastric outlet was widened, the mesh was able to be eroded, subsequently cut with a Soehendra lithotripter and removed with forceps.