Bypass of the bypass pitfalls of endoscopic ultrasound-guided gastrointestinalstomy in a patient with Roux-en-Y gastric bypass and a frozen abdomen. A 56-year-old female with a history of open Roux-en-Y gastric bypass complicated by multiple adhesions presented with nausea and recurrent vomiting, in the setting of an iatrogenic gastric outlet obstruction at the pylorus level and a gastro-gastric fistula representing the dominant exit of the gastric pouch. In the setting of a frozen abdomen, we opted to perform an EOS-guided gastro-diurnal anastomosis between the remnant stomach and the 4th diurnal portion for palliation of iatrogenic gastric outlet obstruction. One day post the procedure, the patient presented to the emergency department with severe abdominal pain and guarding. CT abdomen pelvis was worrisome for traction separation as indicated by free gas and fluids in the site of the featured gastroenteric anastomosis. Urgent laparoscopy was performed. However, given the frozen nature of the abdomen, they could not identify the site of the leak nor intervene surgically. Hence, we opted for another endoscopy. On fluoroscopy, an area of the hessens at the gastroenterostomy site was visualized as evident by contrast extravasation. To salvage the situation endoscopically, we placed a lumen-opposing metal stent coaxial to the first one to approximate the area of the dehessens. Then, we placed two side-by-side fully covered biliary stents with anti-migration phalanges into the afferent and efferent limb of the gastroenterostomy site. Contrast was injected showing good control of the leak. However, her hospital course was further complicated by sepsis due to the anastomotic leak and acute hypoxemic respiratory failure requiring intubation. Repeat CT abdomen pelvis showed improved control of the leak with residual intra-abdominal collection still observed thus requiring placement of drains and a third endoscopy to upgrade the stents. We placed additional biliary fully covered metal stents with anti-migration phalanges adjacent to the previous ones. In addition to a fully covered 10 French plastic stent to the afferent limb thus creating a better seal around the gastroenterostomy site. The patient was extubated 10 days later and transferred to a regular floor where she stayed for pain control and nutrition management. The intra-abdominal infections resolved and the drains were removed as repeat CT abdomen pelvis scans showed no residual leak. The patient was discharged 2 months later. A follow-up EGD was performed and all the stents were removed. Both the afferent and efferent limb of the gastroenterostomy site were patent and to maintain the tract a double-peaked tail plastic stent not shown here was placed extending from the excluded stomach across the gastroenterostomy into the efferent limb. Follow-up CT abdomen pelvis showed no residual leak with good approximation of the small intestine to the excluded stomach. On follow-up the patient is doing well and tolerating oral diet with resolution of nausea and vomiting. In this video we demonstrated that in challenging anatomies including post-surgical ones endoscopy can be performed to provide access and successful palliation. Nevertheless complications could arise and approaching them as a multidisciplinary team that includes experts in surgery and endoscopy is important.

case study

gastric bypass

complications

gastro-gastric fistula

endoscopic procedures