Surgical Science, 2011, 2, 242-245
doi:10.4236/ss.2011.25053 Published Online July 2011 (
Copyright © 2011 SciRes. 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
Received February 18, 2011; revised April 25, 2011; accepted May 27, 2011
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.
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
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
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.
Copyright © 2011 SciRes. SS
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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