EUS guided gastrogastrostomy using lumen-opposing metal stent for management of high-grade gastric outlet obstruction secondary to vertical-banded gastroplasty. Vertical-banded gastroplasty is a mode of restrictive bariatric surgery associated with a high failure rate and increased incidence of long-term complications. Given the high frequency of need for revisional surgeries, the procedure has declined in popularity among bariatric surgeons. Gastroenterologists may be required to manage complications of the VBG, including stenosis of the banded outlet and band erosion. Various endoscopic techniques including balloon dilation, steroid injection, stricturoplasty and placement of fully covered self-expanding metal stents have been described for managing narrowing of the gastric outlet. However, these techniques are associated with a high failure rate. Isolated case reports describe placement of lumen-opposing metal stents across the VBG with varied success, though this carries additional risk of pulsation at the band site and stent migration. A 60-year-old male with a history of vertical-banded gastroplasty 17 years ago presented with a one-year history of poor oral intake, 35-pound weight loss and failure to thrive. Of note, three months prior to presentation, he was diagnosed with stage IV small cell lung cancer. In the year prior to presentation, he had undergone multiple balloon dilations for severe narrowing at the site of his banded gastroplasty, but continued to have recurrent symptoms. On admission, an upper GI series was obtained. Contrast was seen in the proximal stomach and failed to traverse into the antrum. Four hours after the initial study, an abdominal x-ray was obtained that showed contrast remaining in the proximal stomach with no pacification of the distal stomach, small bowel or colon suggesting high-grade obstruction at the site of vertical-banded gastroplasty. After a discussion with the bariatric surgery team, the decision was made to proceed with EGD and stent placement for optimization of the patient's nutritional status. Given a prior history of noted friability and ulceration at the VBG site, there was concern about consequent band erosion with stent placement through the banded gastroplasty outlet. Thus, the decision was made to pursue EUS-guided gastrogastrostomy using labs. On endoscopy, grade B esophagitis was seen in the distal esophagus. A dilated proximal stomach with retained food and fluid was noted. This was removed with suction. The underlying gastric mucosa appeared normal. Evidence of narrowing at the site of vertical-banded gastroplasty was noted. The scope could be advanced beyond it with moderate resistance. The distal stomach, antrum, duodenal bulb, and second portion of the duodenum were normal. Retroflexion performed in the stomach revealed the stenosed vertical-banded gastroplasty site and otherwise normal stomach. With the scope positioned in the gastric fundus and attached to a water jet, a large volume of dilute contrast mixed with methylene blue was infused. This was confirmed on fluoroscopy and infusion continued until optimal distention was achieved. The endoscope was exchanged with a linear echo endoscope and positioned in the proximal stomach. The distended stomach distal to the VBG was visualized. A direct placement of a 20-millimeter electrocautery-enhanced pneumonoposing metal stent was performed to create a gastrogastric anastomosis. The distal flange was deployed under EUS guidance. Following deployment of the proximal flange in the proximal stomach, bluish-colored fluid was seen coursing back through the stent conforming appropriate stent position. The endoscope was traversed through the narrowing created by the VBG, and the distal flange of the lambs was visualized. The lumen of the stent was dilated to 15 millimeters using a wire-guided balloon. This was done under endoscopic and fluoroscopic guidance. Following dilation, the endoscope was advanced through the stent into the distal stomach. The patient tolerated the procedure well without any complications. An upper GI series was obtained the following day and showed free flow of contrast through the pneumonoposing metal stent into the distal stomach and the small bowel. He was started on clear liquids and advanced to a soft mechanical diet within 24 hours. Due to his advanced metastatic disease, he was ultimately discharged to hospice. Vertical banded gastroplasty carries a high risk of gastric pouch stricture and functional gastric pouch obstruction. Endoscopic stenting with lambs is a viable alternative to operative band revisions, especially in post-surgical candidates. EUS-guided gastro-gastrostomy using pneumonoposing metal stent may be associated with earlier recovery and oral intake in malnourished and terminally ill patients. This technique poses fewer complications frequently seen with lambs placement across benign gastrointestinal strictures, including stent migration. Especially in cases of ulceration at the banded outlet, this technique may decrease the risk of band erosion in VBG patients.

endoscopic ultrasound

gastrogastrostomy

lumen-opposing metal stent

gastric outlet obstruction

vertical-banded gastroplasty