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Use of EUS-directed gastro-gastric lumen-apposing metal stents as a viable alternative for gastric remnant and biliary tree access in Roux-en-Y anatomy: A tertiary referral center experience.

Alvaro F Galvez, MD1, Alexa Pesce2, Dane Scantling, DO, MPH1, Lynsey Daniels, MD1, Elizabeth Renza, MD1, Anand Kumar, MD, MPH1, Neal Patel, MD1, Erkanda Ikonomi1. 1Hahnemann University Hospital, 2Drexel University College of Medicine

Objectives: The anatomic challenges presented by Roux-en-Y gastric bypass (RYGB) are formidable. Access to the excluded gastric remnant or biliary tree is a common difficulty for surgeons and endoscopists after gastric reconstruction, especially in patients with multiple revisional surgeries and abundant abdominal adhesions. We present a case series in which gastric remnant access was achieved endoscopically, avoiding the need for surgery.

Methods: Three patients with a history of RYGB were enrolled for this case series. Each was considered high risk for a laparoscopic surgical intervention and each required access to the gastric remnant or biliopancreatic limb for different therapeutic purposes. Endoscopic ultrasound (EUS) was utilized to create a gastro-gastric fistula, maintained open with a lumen-apposing metal stent (LAMS). In one instance, this was done for decompression of the remnant. In the second case, for biliary stenting via ERCP; and in the third, it was utilized for percutaneous feeding access in a patient with failure to thrive.

Results: No patient suffered a leak or complication from stenting. Feeding access, gastric remnant decompression and biliary stenting were all accomplished successfully through the stented gastro-gastric fistula. The LAMS used for ERCP was removed electively 9 weeks after placement. The other 2 LAMS were not removed at follow up and were patent on the most recent imaging in all cases.

Conclusions: Endoscopic creation of a gastro-gastric fistula can be a safe and reliable means of accessing the excluded gastric remnant and biliary tree, avoiding the need for laparoscopic or open surgery. Additional patient enrollment is needed to ascertain long term outcomes.

Keywords: Roux-en-Y gastric bypass (RYGB), lumen-apposing metal stent (LAMS), gastric dilation, biliary leak


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 92291

Program Number: P429

Presentation Session: Poster Session (Non CME)

Presentation Type: Poster

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