Gastric Outlet Remodeling in a Patient with Refractory Gastrojejunal Anastomotic Stricture, First in Human Experience These are our disclosures Symptomatic gastrojejunal anastomotic strictures occur in approximately 20-30% of patients with Roux-en-Y gastric bypass Balloon dilatation is the first line of treatment but has a low response rate Endoscopic therapy includes intralesional steroid injections, incisional therapy and placement of a lumen-opposing metal stent Approximately 40% of patients will fail endoscopic therapy and require revisional surgery We describe a novel endoscopic technique that results in complete remodeling and extension of the GJ anastomosis The following illustrations describe the two-step staged procedure that was used During the first step of the procedure, two lumen-opposing metal stents were placed to connect the gastric pouch with the post-anastomotic small bowel One was placed via the native anastomosis and the other was placed transmurally to create a new GJ fistulas tract located approximately 2-3 cm from the native anastomosis This establishes two fistulas tracts with intervening tissue bridge or septum that comprises a full thickness gastric wall and afferent limb wall as seen in the image on the far right After 3-6 months, the patient is brought back and undergoes a second procedure where the lumen-opposing metal stents are removed and the tissue bridge that connects the now established fistulas tracts is dissected completely This maneuver creates a new and significantly larger GJ anastomosis We present a 56-year-old female with a history of Roux-en-Y gastric bypass and multiple comorbidities The patient was referred for endoscopic management of a symptomatic gastrojejunal anastomotic stricture She had failed prior balloon dilatation and placement of a lumen-opposing metal stent After a multidisciplinary discussion, given the patient's poor surgical candidacy, it was decided to proceed with an attempt at definitive endoscopic management The following video series describe the two steps of the procedure in our patient In the first step, we place two lambs to create a tissue bridge or a septum As seen here, despite prior therapy, there remains significant stenosis of the GJ anastomosis with upstream solid food retention A soft-tip guide wire and nasocystic catheter were passed through the native GJ anastomosis and the small bowel was insufflated with a solution of methylene blue, water, and radiocontrast This was followed by freehand placement of a 20 mm by 10 mm lumen-opposing metal stent into the afferent loop of the small bowel approximately 2 cm from the native GJ anastomosis An additional 20 mm by 10 mm lumen-opposing metal stent was placed through the native GJ anastomosis and deployed under fluoroscopic guidance Both stents were then sutured together to prevent distal migration Water-soluble contrast was then injected into the gastric pouch to ensure absence of a leak and the patient was discharged home on a soft diet The patient progressed well, was asymptomatic for 3 months and gained some weight An interval EGD-EUS was performed after 3 months to assess the septum Due to significant vascularity of the septum, it was decided not to proceed with septotomy at the time and instead placed two endoscopic sutures at either end of the septum to prophylactically ligate the blood vessels The patient progressed well and underwent step 2 of the procedure 6 months after step 1 As seen here, both lumen-opposing metal stents were removed with the rat-toothed forceps The technique of suturing the two lumen-opposing stents together is both effective at preventing distal migration and at facilitating simultaneous removal In order to evaluate the entire thickness of the septum, the transducer of the EUS scope was then passed through one of the GJ fistulas and the small bowel was lavaged with a copious amount of water to better delineate the anatomy On Doppler studies, we note a significant decrease in vascularity of the septum this time around It was hence decided to proceed with septotomy A soft tip guide wire was passed into the small bowel through one of the fistulas and the scope was withdrawn while leaving the guide wire in place The scope was then reintroduced along the guide wire and advanced through the second fistula and the soft tip of the guide wire was then grasped and the scope was withdrawn from the patient to create a guide wire loop As seen here, when external traction is applied to the wire loop, it hooks the septum and pulls it away from the posterior wall of the afferent limb The loop essentially serves as a surgical ligature wood during septotomy by providing traction and guiding the plane of dissection As seen here, backward loop traction assists with application of a prophylactic hemoclip at each end of the septum by pulling the septum towards the scope and creating effective counterpressure A scissor-type EST knife was then used to dissect the tissue bridge along a plane that is parallel to the wire loop As seen here, we encountered minor bleeding during the dissection that was easily controlled with the hemostatic forceps Dissection was continued in layers from the gastric side until the submucosa of the small bowel was visible Dynamic adjustment of outward traction on the loop was helpful in bringing the tissue bridge toward the endoscope and creating an effective counterforce for the EST knife It also allowed us to constantly reorient ourselves to the required plane of dissection An insulated tip knife was finally used to take down the septum and to prevent inadvertent thermal injury of the posterior wall of the afferent limb Here we see complete takedown of the septum between the two fistulas and creation of a large egeonostomosis measuring approximately 2-3 cm Thorough examination of the dissection bed did not reveal any transmural defects at both ends and the posterior wall of the afferent loop was completely intact Water-soluble contrast was subsequently injected into the gastric pouch and flowed unrestricted into the afferent loop There was no leak or free air noted Intra-procedural IV antibiotics were administered Following the procedure, the patient was admitted overnight for observation and started on a clear liquid diet There were no adverse events encountered On clinical follow-up, the patient had no recurrence of symptoms This is an illustration of the patient's anatomy before and after the procedure In conclusion, to the best of our knowledge, this is the first in-human case that demonstrates feasibility of a novel technique involving septotomy of a tissue bridge between two closely placed lumen-opposing metal stents connecting two hollow viscus This resulted in remodeling and significant widening of a strictured gastrojejunal anastomosis in our patient and may offer a viable and less invasive alternative for patients with refractory GJ strictures that would otherwise require surgery Thank you for your attention

endoscopic technique

gastrojejunal anastomotic strictures

Roux-en-Y gastric bypass

lumen-opposing metal stents

septotomy