Endoscopic ultrasound guided gastrogastrostomy and transoral outlet occlusion for endoscopic reversion of a Roux-en-Y gastric bypass for malnutrition and failure to thrive. These are our disclosures. Roux-en-Y gastric bypass is the second most performed surgical procedure for the treatment of obesity in the United States. Malnutrition is a well-known complication of this procedure, especially in patients who develop certain medical conditions such as malignant neoplasms and certain surgical complications. Surgical reversion of a Roux-en-Y gastric bypass can be associated with increased morbidity and mortality. To date, there is a paucity of endoscopic options aimed at partially reversing the metabolic effects of Roux-en-Y gastric bypass in this population. The 59-year-old female with a history of a Roux-en-Y gastric bypass for morbid obesity and protein calorie malnutrition was admitted with septic shock secondary to intra-abdominal abscesses due to a dislodged PEG tube placed for management of failure to thrive. CT abdomen revealed a large intra-abdominal abscess. She underwent expletory laparotomy with G-tube removal, gastric wedge resection, J-tube insertion, and VAC insertion. Her course was complicated by the inadvertent removal of her J-tube. After a multidisciplinary discussion, inability to place a percutaneous G-tube due to the presence of a wound VAC device, non-surgical candidacy for surgical reversion, and previous complications, the patient opted to undergo a two-staged endoscopic reversal of her Roux-en-Y gastric bypass. The procedure consisted of two main stages. Stage 1, after a standard upper endoscopic exam, EUS-guided gastrogastrostomy was created using a lumen-opposing metal stent. Stage 2 consisted of a transoral outlet occlusion of the gastrojejunal anastomosis using endoscopic sutures after a standard upper endoscopic exam of the remnant stomach and duodenum. We will be discussing both stages. An upper endoscopy was performed, revealing a 6-centimeter gastric pouch and a dilated gastrojejunal anastomosis. Known luminal lesions were appreciated. Endosynographic examination revealed gastric rugae and a fluid-filled lumen consistent with the remnant stomach. The gastric pouch and the excluded stomach were punctured under EUS guidance with a 19-gauge FNA needle. When sufficient gastric distension was achieved, a cautery-enhanced 20 by 10 LAMS was deployed using a freehand technique with both flanges in close approximation to the walls of the gastric pouch and the remnant stomach. The LAMS was then dilated to 18 millimeters under direct endoscopic and fluoroscopic guidance. Visual confirmation of the excluded stomach was obtained, and the procedure was then terminated. Two weeks later, the patient returned for the second stage of her procedure. After accessing the remnant stomach through the gastric-gastric access via the previously placed lambs, no obvious lesions were noted in the gastric body and tremenda pylorus. Gentle retroflexion revealed excellent apposition of the distal flange of the lambs to the gastric remnant wall. To perform completion of endoscopic reversion of a Roux-en-Y gastric bypass using a trans-oral outlet occlusion technique, first, a 1.5 to 2 cm circumferential area of mucosal tissue at the gastrojejunal anastomosis rim was ablated using APC. Next, an endoscopic suturing system using a single 2-O non-absorbable prolipropylene suture was used to place multiple full-thickness stitches around the gastrojejunal anastomosis. These stitches were placed in a running fashion. The suture was then cinched. This was successful in achieving complete closure of the gastrojejunal anastomosis. The patient had no post-procedural complications and was discharged on open capsule PPI, liquid sucralfate, and an anti-emetic regimen. At a two-week post-procedure follow-up, the patient continues to do well with an excellent appetite and weight regain of approximately 3.5 kg. Malnutrition can develop in certain patients with a history of Rheum Y gastric bypass and other associated comorbidities. There is a paucity of data on endoscopic reversion of a Rheum Y gastric bypass, and only a handful of reports have been published aiming for a partial reversion of the Rheum Y gastric bypass, with no targeted therapy for the gastrojejunal anastomosis, which can help prevent the bypass of the oral intake of these patients and thus potentially improve nutritional parameters. In conclusion, combined endoscopic ultrasound-guided gastrogastrostomy and transoral outlet occlusion for the endoscopic reversion of a Rheum Y gastric bypass appears to be technically feasible in patients with failure to thrive after Rheum Y gastric bypass. Larger studies are necessary to examine long-term efficacy and safety in this population.

endoscopic ultrasound-guided gastrogastrostomy

transoral outlet occlusion

endoscopic reversion

Roux-en-Y gastric bypass

malnutrition