Endoscopic brawn and pteroenterostomy for the management of bile acid reflux post-whipple surgery. Morbidity post-whipple procedure is estimated to be approximately 30 to 60 percent with the most common complications including bile acid reflux gastropathy and delayed gastric emptying. Bile acid reflux is primarily treated with medical management and lifestyle modification. In severe cases, surgical reconstruction can be necessitated after failure of first-line therapy. The image on the left shows the anatomy of the GI tract post-whipple surgery. Here you can see the afferent or pancreatic obiliary limb labeled as A, efferent limb labeled as E, and the stomach labeled as S. In patients post-whipple surgery, bile drains from the afferent limb into the stomach and then later into the efferent limb. However, in some patients, their bile acid reflux can be severe enough to cause inflammation in the stomach and lead to bile acid gastropathy. In most cases, this is initially managed with medical intervention. However, in severe cases, surgical interventions like Roux-en-Y reconstruction, Bilroth 2, and Bronn and Tarot enterostomy can be used with the goal of redirecting the bile away from the stomach and instead directly into the efferent limb. A 62-year-old female with a history notable for chronic pancreatitis of unknown etiology and an expanding pancreatic head lesion of unclear etiology status post-whipple surgery presented for GI evaluation with severe nausea and bilious emesis for more than three years. Over the course of the next three years after her whipple procedure, the patient attempted lifestyle modification and medical management of her reflux nausea and emesis. During this time, she had 26 emergency department visits, which resulted in 15 admissions, innumerable outpatient follow-ups, and multiple EGDs, all of which showed worsening bile acid gastropathy. The patient's failed lifestyle modifications include dietary changes, tobacco cessation, and weight loss. Failed medical management included proton pump inhibitors twice daily, carafate, multiple bile acid sequestrants, and multiple anti-emetics. Unfortunately, the patient failed all medical management and lifestyle modification. EGD after this failure showed LA grade B reflux esophagitis, a large amount of reflux bile acid in the stomach, diffuse bile acid gastropathy, and negative H. pylori biopsies. Gastric images from this EGD can be seen on the left. Given continued severe bile acid reflux, nausea, and emesis after a multidisciplinary discussion including the patient in which she voiced hesitancy to pursue another surgical intervention, a decision was made to pursue an EUS-guided enteroenterostomy as an alternative to a surgical bron-enteroenterostomy. For a better visualization of the patient's anatomy after the whipple procedure, we again see the image on the left. Here we can identify the pancreatic obiliary or afferent limb labeled as A, efferent limb labeled as E, stomach labeled as S, and the gastrojejunal anastomosis that defines a separation point between these two limbs labeled with a star. Additionally, we can see the green arrows that represent the flow of bile in the post-whipple anatomy moving from the liver, which is not pictured, through the afferent limb, into the stomach, and then down into the efferent limb. The image on the right depicts the endoscopic view of the openings of the afferent and efferent limbs as seen from the stomach. On the right, we can see the proposed EUS-guided enteroenterostomy procedure. Here, the jejunal-jejunal anastomosis between the afferent and efferent limbs is labeled at the top of the white arrow. As is evident with the change in path with the green arrows, this anastomosis allows for the bile acid to be diverted from the afferent limb into the efferent limb instead of refluxing back into the stomach, reducing gastropathy and reflux symptoms. To initiate the EUS-guided bron-enteroenterostomy, we first identified the patient's stomach and gastrojejunal anastomosis, which showed features of bile acid gastropathy, which can be seen here. We then examined and intubated the afferent and efferent limbs of the anastomosis created during the Whipple procedure. After intubating both limbs, it was determined that the afferent limb was positioned in such a way that the passage of the EUS scope was easier compared to the more angulated efferent limb. Next, the efferent limb was flooded with a mixture of contrast and saline so that it could be identified on fluoroscopy, and a guidewire was threaded into the efferent limb. After this was completed, the scope was withdrawn. This process can again be visualized under fluoroscopy here as we see an image of the wire in place in the efferent limb, which is indicated at the top of the yellow arrow. After the wire was placed, an 18 millimeter biliary extraction balloon was passed over the wire and inflated in the efferent limb, which is seen again at the tip of the yellow arrow. Contrast was then injected and the balloon remained in place for continuous flooding. Here we can see fluoroscopic evidence of the contrast flowing in the efferent limb. Next, the EUS scope was introduced into the afferent limb as is seen in this video. The limb was chosen for the EUS scope as it was less angulated in the efferent limb, so it would allow for easier passage. Once the EUS scope was in place, we can see the fluoroscopic image showing the biliary extraction balloons into the tip of the yellow arrow in the efferent limb labeled as E, the EUS scope intimating the efferent limb labeled as A, and the easier angulation angle of the efferent compared to the efferent limb. Under EUS guidance, the 20 millimeter by 10 millimeter LAMS was then placed from the efferent limb into the efferent limb, creating an anastomosis. The deployment of the LAMS can be visualized on EUS at the tip of the yellow arrow. The deployment of the LAMS can again be visualized on endoscopy with visualization of the proximal flange and the efferent limb during deployment. After LAMS deployment, we can see the saline and contrast mixture that previously flooded the efferent limb rushing through the anastomosis into the efferent limb. With confirmation of the anastomotic patency, the LAMS was then dilated up to 15 millimeters using a through-the-scope dilation balloon. The final dilated patent LAMS can be seen here looking through the scent from the efferent into the efferent limbs. LAMS placement was then confirmed on fluoroscopy. Here we can see the LAMS successfully placed between the efferent and efferent limbs. We can also appreciate the movement of both air and contrast through the stent into the efferent limb without any evidence of leakage or obstruction. Postoperatively, the patient tolerated the procedure well and was discharged home without complication the same day and repeat EGD was planned for six months. At six-month follow-up, the patient reported significant improvement in her reflux without any episodes of nausea or emesis. Given this, the LAMS was removed, which can be seen in the image on the left. Additionally, post LAMS removal, we can see the patent anastomosis in the two images on the right. One year post LAMS placement, the patient underwent a follow-up EGD, which can be seen here. Initially, her stomach can be visualized without any evidence of bile acid gastropathy, a significant improvement for previous EGDs. Then, the efferent limb was intubated and the patent anastomosis can be identified with bile seen refluxing from the efferent to the efferent limbs as intended. Additionally, for confirmation of anastomotic patency, fluoroscopic imaging from the one-year post LAMS follow-up is seen here with contrast freely flowing through the anastomosis without leakage seen at the tip of the yellow arrow. In conclusion, our case highlights the use of an EUS-guided enteroenterostomy as a minimally invasive endoscopic alternative to Braun enteroenterostomy to manage severe intractable bile reflux after Whipple surgery. While medical and lifestyle modifications are commonly used in the management of bile acid reflux for intractable cases, surgical interventions are often pursued. While effective in improving bile acid reflux, these surgical procedures have an inherent risk of prolonged structural complications in up to 30% of cases and non-negligible morbidity and mortality rates associated with an irreversible intervention. Endoscopic Braun enteroenterostomy is a promising alternative to surgical procedures, especially in patients who are poor candidates or refuse further surgeries.

endoscopic interventions

bile acid reflux

Whipple surgery

EUS-guided enteroenterostomy

minimally invasive approach