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INTRODUCTION: Vertical banded gastroplasty (VBG) is a restrictive bariatric procedure performed by creating a stapled proximal gastric pouch with a lesser curvature outlet, reinforced with a prosthetic band. Popular in the 1980s, this procedure can result in a fixed outlet obstruction and progressive pouch dilation over time. The standard method of revision has traditionally been a complex and difficult operation. We report our experience with endoscopic management of strictured VBG. METHODS: Three patients with previous VBG presented with persistent nausea and vomiting. All underwent preoperative workup demonstrating high-grade gastric pouch outlet obstruction. Endoscopic gastric band division was planned for all patients. An endoscope was passed transorally and was used to identify the common wall between the gastric pouch and distal stomach; this was marked with a submucosal injection of blue dye to maintain orientation. Using a combination of a needle knife cautery and a pull type sphincterotome for both antegrade and retrograde approaches, an incision was made from the strictured opening along the stapled common wall of the stomach. In one case, the gastric band was unable to be divided in this manner, as it was probably polypropylene vs silastic. In this case, an endoscopic gastrogastrostomy was performed from the proximal pouch to the distal stomach, using the staple line of the gastroplasty as a landmark. A second endoscope was used to provide transillumination and improved visualization, similar to the technique used in the creation of percutaneous endoscopic gastrostomy tubes. An opening was made by a direct puncture between the proximal pouch and the distal stomach directly through the staple line using the needle knife. Using the dual endoscopes, we were able to visualize entry of the needle knife into the distal stomach across the common wall. This tunnel was dilated with a 12 mm endoscopic balloon over a wire followed by placement of a 105 mm (length) by 23 mm (diameter) fully covered stent. RESULTS: The procedure was well tolerated. Operative time was between 35 and 135 min. Upper gastrointestinal contrast studies on the first postoperative day revealed resolution of the outlet obstruction. All patients were discharged within three days. The patients tolerated resumption of diet and are doing well 6 weeks following the procedures. The stent was removed after 9 weeks without sequelae. CONCLUSIONS: Endoscopic reversal of VBG is feasible and safe. The material from which the band was fashioned directly affected the ease and ability with which it was divided; soft silastic was easy and polypropylene mesh impossible to divide, which necessitated direct puncture though the common gastric wall. The biliary sphincterotome was well suited for the procedure and the use of two upper endoscopes permitted safe transillumination for the procedure.