Creation of EUS-guided fresh anastomosis between gastric pouch and Roux limb for management of refractory gastrointestinal strictures in Roux-en-Y gastric bypass patients, a case series. Obesity is a chronic disease and global epidemic. Bariatric procedures are most effective in inducing weight loss. Roux-en-Y gastric bypass is the second most common procedure after sleeve gastrectomy. A small proximal gastric pouch is created, which is separated from the distal stomach. This small pouch is then anastomosed to a Roux limb of small bowel that is 75-150 centimeters in length. 70% excess weight loss can be expected two years after surgery. Gastrojejunal stenosis, defined as a stomal diameter of less than 10 mm, can affect up to 15% of these patients. Apart from technical factors associated with surgery, diabetes, H. pylori, smoking and NSAIDs can be associated with stenosis. These factors result in ischemia of the anastomosis, resulting in strictures. Although surgical revision can be attempted, it is technically challenging and is associated with increased morbidity. Therefore, endoscopic interventions remain the first line of therapy. Endoscopic balloon dilation is one of the most commonly performed procedures for stricture and has a response rate of upwards of 70%. For strictures that fail to respond to balloon dilations, we offer the placement of lumen opposing metal stent across the stricture as demonstrated here. After passing a wire across the severe gastrojejunal stricture, a 20 x 10 mm lumen opposing metal stent is passed across the stricture. This is followed by deployment of the distal flange in the Roux limb, followed by proximal flange in the gastric pouch. The stent can be dilated as well. Our own single center experience, which included 21 patients, showed a technical and short-term clinical success rate of 100% with a long-term success rate of 70%. All but 4 patients responded to lumen opposing metal stents. These 4 patients that remained refractory to balloon dilation and stent placement were treated with a novel technique where a fresh anastomosis is created between a gastric pouch and Roux limb as an alternative to surgical revision. We describe the technique here. Here we see a severe gastrojejunal stenosis. After dilation of the stenosis, the Roux limb is intubated and flooded with water mixed with contrast, which can be seen on this fluoro image. Then a guide wire is passed into the Roux limb and the scope is withdrawn. The guide wire can now be seen in the Roux limb fluoroscopically. An 18mm balloon is then passed over the wire and the Roux limb is further injected with contrast and fluid as seen here. Then an EUS scope is passed into the gastric pouch. From the gastric pouch, the distended Roux limb is identified and a 20x10mm cotri-enhanced lumen opposing metal stent is placed between the gastric pouch and the Roux limb. Here we can see the distal flange being deployed in the gastric pouch. The stent can be seen fluoroscopically and then endoscopically. Case 1. A 69-year-old female with a history of Roux-en-Y gastric bypass who has had multiple dilations of anastomotic stricture presents with dysphagia, vomiting and weight loss. EGD revealed a severe gastrojejunal stenosis, which was initially dilated and then stented with a 20x10mm lumen opposing metal stent. She had symptomatic improvement and 3 months later the lumen opposing metal stent was removed. She had recurrence of symptoms a month after removing the lumen opposing metal stent. Therefore, a decision was made to create a new anastomosis between the gastric pouch and Roux limb. Using the previously described technique, a cotri-enhanced 20x10mm lumen opposing metal stent is placed between the gastric pouch and Roux limb. This can now be seen endoscopically adjacent to a severe refractory old gastrojejunal stenosis. Patient had complete resolution of obstructive symptoms and an EGD was repeated 4 months later. Here we can see the lumen opposing metal stent between the gastric pouch and the Roux limb. This 20x10mm lumen opposing metal stent is removed and a fresh anastomosis can be seen between the gastric pouch and the Roux limb. On follow-up, patient remains asymptomatic and has gained 2kgs after the removal of limbs. Case 2. A 49-year-old female with a history of Roux-en-Y gastric bypass who's had multiple prior dilations for strictures presents with dysphagia, vomiting and weight loss. Her initial EGD showed a normal gastric pouch with an asthmatic ulcer and sutures which were removed. Initial therapy was optimized with PPI and carophate. Persistent ulcer and mild stricture along with an angulation was noted which was treated with lumen opposing metal stent. Patient had recurrence of symptoms after the removal of lumen opposing metal stent. Given persistent symptoms, a repeat EGD was planned. Here we see a normal gastric pouch and a gastrojejunal anastomosis that leads directly to the blind Roux limb. An acute angulation is encountered in order to intubate the Roux limb which can be seen here. This acute angulation was thought to be the cause of her obstructive symptoms and therefore a fresh anastomosis between blind limb and Roux limb was proposed. Using the previously described technique, a 20x10mm cautery enhanced lumen opposing metal stent was placed between the blind limb and the Roux limb creating a new anastomosis. Patient remains asymptomatic post procedure and continues to have weight gain. Case 3. A 63 year old female with a history of Roux and Y gastric bypass who's had multiple dilations of anastomotic stricture presents with dysphagia, vomiting and weight loss. A severe gastrojejunal stenosis was noted which was treated with lumen opposing metal stent. Due to recurrence of her symptoms after removal of lumen opposing metal stent, a decision was made to create a fresh anastomosis between the gastric pouch and Roux limb. Patient remains asymptomatic and a fresh anastomosis can be seen here. Case 4. A 39 year old female with a history of gastrojejunal stenosis treated with balloon dilation and LAMS presents with weight loss and dysphagia. In prior failed endoscopic therapies a new gastrojejunostomy was created between the pouch and the Roux limb. A patent and fresh anastomosis can be seen after removal of lumen opposing metal stent. Currently the patient remains asymptomatic. In summary all 4 patients remain asymptomatic after the creation of new anastomosis. Gastrojejunal stenosis which is a common complication post gastric bypass responds very well to balloon dilations. Although surgical revision can be attempted it carries high morbidity. Lumen opposing metal stent can be placed across the stricture in patients who fail to respond to balloon dilations. In strictures that remain refractory to stent placement this novel technique whereby a new anastomosis is created between the gastric pouch and Roux limb can unveil a promising new approach. Larger studies with long term follow up are needed to evaluate the safety and effectiveness of this novel approach.

EUS-guided anastomosis

Roux-en-Y gastric bypass

gastrointestinal strictures

lumen opposing metal stent

gastrojejunal stenosis