Description:
Introduction
A 44 year old female with a past history of Roux-en-Y gastric bypass underwent an emergent antrectomy for a perforated peptic ulcer. This resulted in a completely excluded remnant stomach which required a permanent surgical gastrostomy tube for drainage of secretions.
This figure shows the anatomy after Roux-en-Y gastric bypass. The patient then underwent an emergency antrectomy that left behind a completely excluded gastric remnant as seen here. This required placement of a surgical gastrostomy tube for drainage.
Despite the G-tube, the patient continued to have chronic abdominal pain and distention for many months after surgery. She was felt to be a poor surgical candidate and endoscopic reversal of the gastric bypass was requested.
We have used simultaneous antegrade and retrograde endoscopy, the SARE technique, in the treatment of post-operative and post-radiation complete esophageal obstruction. The antegrade endoscope is inserted via the mouth and the retrograde scope inserted percutaneously via the G-tube tract to establish luminal patency.
A similar approach was used for reversal of the gastric bypass in this case. This video demonstrates the endoscopic technique to reconnect the gastric pouch to the excluded stomach.
Endoscopic Technique
Contrast was first injected through the G-tube to delineate the excluded gastric remnant. A guidewire was placed through the G-tube to maintain access.
The antegrade endoscope was advanced into the gastric pouch and revealed a patent, healthy gastro-jejunal anastomosis. No staple line was visible.
The G-tube tract was dilated with a 10 mm balloon over a guidewire. A transnasal endoscope was percutaneously advanced retrograde into the excluded gastric remnant via the G-tube tract alongside the wire.
Indentation and transillumination from the antegrade endoscope was clearly seen on retrograde endoscopy as seen here. The close proximity of the two endoscopes was also confirmed on fluoroscopy.
A 19-gauge EUS needle was advanced from the gastric pouch into the excluded gastric remnant as seen here on simultaneous retrograde endoscopy. This allowed access to the excluded gastric remnant.
A guidewire was coiled into the excluded stomach through the needle.
This antegrade view shows a 10 mm balloon dilator passed over a guidewire. The newly created gastro-gastric tract was then successfully dilated. Appropropriate positioning of the balloon was confirmed on fluoroscopy. Retrograde endoscopic views during balloon dilation are seen in the inset at the top right of the screen.
The excluded gastric remnant could now be inspected via the antegrade endoscope. Light from the retrograde scope is seen shining through the gastro-gastric opening.
The retrograde endoscope is now able to be advanced into the gastric pouch through the newly created conduit.
Next, a 10 mm by 4 cm fully covered metal biliary stent was to be placed to establish and maintain this conduit. The stent delivery system is shown here being advanced across the new tract.
The stent was then deployed under fluoroscopic and simultaneous antegrade and retrograde endoscopic guidance. Once again the inset shows the stent in good position on retrograde views.
Antegrade endoscopy also shows the stent well situated in the gastric pouch and reconnecting the pouch to the excluded gastric remnant.
Follow-up
The patient was admitted for observation and discharged without complications. The G-tube was clamped and there was prompt relief of symptoms after stent placement.
The patient returned after one week and the stent was electively removed as planned. The upper endoscope could be easily advanced into the excluded gastric remnant via the newly created gastro-gastric conduit as shown in the middle photo. The opening was widely patent as seen in the bottom picture.
The tract was then serially dilated to 20 mm with CRE balloons.
Conclusion
This video demonstrates the successful creation of a gastro-gastric conduit after gastric bypass using simultaneous antegrade and retrograde endoscopy with fluoroscopic guidance.
This technique can be used to reconnect the gastric pouch with the excluded stomach for endoscopic reversal of gastric bypass surgery, if required in select patients.
Contributed By:
Mihir S. Wagh, MD, University of Florida
