Objective: Gastrostomy tube (GT) placement after Roux-en-Y gastric bypass can be challenging. Novel, minimally invasive approaches are needed to access the gastric remnant in these patients. Our objective is to present an innovative method of endoscopic ultrasound (EUS)-guided GT placement.
Procedure Description: A 55 year-old morbidly obese female underwent reoperative, open retrocolic Roux-en-Y gastric bypass, and subsequently developed chronic nausea and failure to thrive. We opted to place a GT for gastric decompression and enteral nutrition; however, the gastric remnant was collapsed and not readily accessible percutaneously and a laparoscopic approach was unreasonable due to dense adhesions. We combined EUS and fluoroscopy to access the gastric remnant, and performed this procedure under general anesthesia. Procedural steps:
(1) EUS identification of gastric remnant: We introduced a EUS scope into the proximal Roux limb, and ultrasonographically identified the posterior wall of the gastric remnant.
(2) EUS-guided gastric remnant cannulation: We inserted a 19-gauge biopsy needle through the EUS scope and ultrasonographically guided it across the intestinal wall, into the gastric lumen.
(3) Fluoroscopic confirmation of gastric cannulation: We injected radiopaque contrast material through the biopsy needle to confirm placement in the remnant.
(4) Gastric remnant insufflation: We insufflated the gastric remnant through the biopsy needle to approximate it to the anterior abdominal wall.
(5) Fluoroscopcally guided percutaneous GT placement: We placed a 12 French GT using Seldinger technique.
The patient had an uneventful recovery from this procedure.
Conclusion: We describe a safe, novel, and minimally invasive technique for placement of a GT into the bypassed gastric remnant. To our knowledge, this is the first report of successful EUS-guided GT placement, which has the potential to significantly impact the management of patients following gastric bypass.
Program Number: P372