Endoscopic myotomy for management of anastomotic stricture following Whipple. The Whipple procedure is often the surgical treatment of choice in patients with pancreatic cancer. Even at large volume medical seizures, the Whipple procedure is notorious for complications and as with many abdominal surgeries, postoperative strictures may develop. Postoperative strictures can be very troublesome from a symptomatic standpoint and treatment can range from balloon dilation and stenting to surgical revision. Here we demonstrate endoscopic myotomy at the level of the gastric outlet to treat efferent limb stricture in a patient with Whipple anatomy. The patient is a 75-year-old male with a past medical history significant for having undergone the Whipple procedure to treat pancreatic cancer 25 years prior. He presented with nausea, fullness, and weight loss in the setting of several hospitalizations. The patient initially underwent multiple balloon dilation sessions followed by placement of a 15x10mm luminoposing stent across the gastric outlet. The patient's symptoms returned however and endoscopic ultrasound guided gastrogynectomy was performed. A 10mmx4cm covered stent was also placed across the native gastric outlet replacing the previous 15x10mm luminoposing stent. Here is a representation of normal quote-unquote gastric anatomy following a successful Whipple procedure. The efferent limb and stomach contents are able to progress to the efferent limb. Here is a representation of our patient's anatomy with a stricture obscuring much of the native gastric outlet. The patient had multiple dilation sessions with a sutured luminoposing stent placed following this. After failure of the gastric outlet stenting with the sutured luminoposing stent, EUSGJ was performed and the previous sutured stent across the gastric outlet was removed. Then a covered stent was placed across the native gastric outlet as part of an intended bridge. The patient tolerated EUSGJ well and was able to resume oral intake but this was only intended as a bridge to a more long-term solution. A muscular septum was present between the two orifices, that is the native gastric outlet now traversed by a stent and the EUSGJ also traversed by a stent. Thus, endoscopic myotomy of the septum was planned as a way to join these sites and create a large and patent gastric outlet. Here is a representation of the proposed site of myotomy through the septum that remains between the stents. Here is a video of the initial anatomy at the time of myotomy. The EUSGJ opening is on the left while the native gastric outlet is on the right. Here is the endoscopic cutting of the septum in progress. Further cutting is seen here proceeding distally. and here the base of the septum is being reached. The endoscope is now inserted through the area of the hematoma, and as can be seen, the previous septum is now cut, and the small bowel, that is the efferent limb, can be visualized through the opening. A 20 by 10 millimeter lumen opposing stent was then deployed across the newly widened gastrogallic. The patient returned one week later with abdominal pain, and thus, the decision was made for the stent to be removed. This led to symptomatic improvement for the patient. This video is from follow-up examination and at the two o'clock position the patent gastric outlet can be seen. Here's a representation of the patient's anatomy before the endoscopic gastric myotomy and here's a representation of the patient's anatomy after. Again on the left is the gastric outlet before the procedure seen at the 12 o'clock position and on the right is the gastric outlet after the procedure seen at the two o'clock position. For our conclusions the patient had complicated anatomy to the previous squibble procedure over 25 years prior and resulting stricture that was refractory to therapy. EUSGJ was helpful as a bridge to more definitive treatment but leaving a lumen opposing stent in place long term is preferably avoided. Myotomy at the gastric outlet allowed the removal of stents and may be an option for patients with complicated upper GI anatomy and resulting strictures. Although post Whipple anatomy itself is uncommon, gastric bypass another source of anastomotic strictures is an increasingly common phenotype in the United States. In these patients myotomy may be an option to treat strictures at the gastric outlet level such as those at the efferent level.

Endoscopic myotomy

anastomotic stricture

Whipple procedure

pancreatic cancer

gastric outlet