Endoscopic ultrasound-guided gastric peroral endoscopic myotomy for the treatment of benign gastric outlet obstruction in the remnant stomach in a patient with Roux-en-Y gastric bypass. These are our disclosures. Roux-en-Y gastric bypass is the second must-perform surgical procedure for the treatment of obesity in the U.S. Benign and malignant gastric outlet obstruction at the remnant stomach can potentially be life-threatening. To date, there's a paucity of endoscopic options aimed at partially reversing gastric outlet obstruction of the remnant stomach in patients with Roux-en-Y gastric bypass anatomy, the majority of which are palliative. A 55-year-old female with a 20-year history of Roux-en-Y gastric bypass for neurodiversity presented with abdominal pain and distension. She was previously found to have a chronically dilated gastric remnant for which she underwent pectoral placement and percutaneous endoscopy with the inability to transverse the pylorus. Outside hospital CT scan and MRI of the abdomen revealed no obvious cause of gastric outlet obstruction. On presentation to our hospital, the patient's pectoral had fallen out and she presented with marked abdominal distension and abdominal pain as seen on this CT scan. After a multidisciplinary discussion and due to the patient's preference to avoid a laparoscopic gastric adrenostomy to the remnant stomach and previous spective dislodgement, she opted to undergo a three-stage procedure for the treatment of benign gastric outlet obstruction in the remnant stomach. Stage one of her procedure consisted of EOS-guided gastric access for temporary endoscopy with a luminiposing metal stent. This was followed by operendoscopic examination of the remnant stomach with biopsies. And the sonographic examination revealed a massively dilated remnant stomach for which patient underwent placement of a 20 millimeter by 10 millimeter cautery enhanced luminiposing metal stent under direct endosonographic and fluoroscopic guidance. During this maneuver approximately 1.3 liters of fluid were suctioned and subsequently the stent was dilated up to 18 millimeters using a through the scope balloon dilator. Endoscopic examination of the remnant stomach revealed the previous side of the pective placement and also showed that the pylorus was non-patent. Nevertheless, no obvious lesions or masses were appreciated that could have accounted for the patient's gastric outlet obstruction. Biopsies of this area were unremarkable. Two weeks later after index procedure, patient returned for stage 2 part 1 of her procedure. This consisted of luminiposing metal stent placement at the pylorus followed by endoscopic examination of the duodenum and endosonographic examination of the anthropyleric region, duodenum, ampulla, and head of the pancreas. After successful placement of a 0.035 inch guided wire through the pylorus, a 20 millimeter by 10 millimeter non-cautery enhanced luminiposing metal stent was placed across the pylorus. This was followed by dilation of the saddle of the stent up to 18 millimeters with a through the scope balloon dilator. Subsequently, endoscopic suturing or anchoring of the stent to the gastric mucosa was performed and one 2.0 polypropylene suture was subsequently placed. This allowed endoscopic and endosonographic examination of the duodenum and head of the pancreas. Follow-up CT scan showed adequate placement of both the gastro-gastric and pyloric luminiposing metal stents. As shown before, a detailed exam to identify the cause of her gastric allot obstruction was revealing. This included endoscopy with biopsies of the pylorus and the sonographic examination via the lamps both into the remnant stomach and duodenum and cross-sectional imaging which included two CT scans and one MRI, all of which were unrevealing. We thus believe that her current gastric allot obstruction was a result of long-term vagal denervation post-roentgen gastric bypass surgery and thus proceeded to a gastric perorondoscopic myotomy in the remnant stomach. Two weeks later after stage 2, patient returned for stage 3 part 2 of her procedure. This included removal of the previously placed transpyloric lamps followed by gastric peroral endoscopic myotomy and subsequent removal of the previously placed gastro-gastric lamps. Using a dilution of normal saline mixed with indigo carmine, a submucosal injection was performed on the greater curvature of the remnant stomach, 5 centimeters proximal to the pylorus. A transverse mucosotomy was performed using an electro-surgical knife. This was followed by successful tunneling and preventive cauterization of small vessels. Once the pyloric ring was identified, we proceeded to carefully performing a full thickness myotomy of the pylorus. This was successful. This myotomy was also extended one centimeter into the antrum of the stomach. The mucosotomy was closed using endoscopic suturing and a 1,2.0 polypropylene suture. This is the appearance of the pylorus pre-GPOEM with subsequent marked improvement in the patency on diameter of it post-GPOEM. Endoscopy performed one day post-GPOEM demonstrated free flow of contracin to the first and second portion of the duodenum and no leak. Therefore, the gastro-gastric lamps was removed. Patient remained symptom-free at five months post-procedure. Benign gastric outlet obstruction in the remnant stomach is a rare complication in patients with Roux-en-Y gastric bypass anatomy. Vagal efferents are reduced after Roux-en-Y gastric bypass surgery and this can have long-term detrimental effects in the emptying of the stomach and on the function and tone of the intrapyloric region. There is a positive data on the treatment of gastric outlet obstruction at the remnant stomach in patients with Roux-en-Y gastric bypass and only a handful of reports have been published aiming to be palliative and with few non-invasive options. Endoscopic ultrasound guided gastric access for temporary endoscopy continues to be relevant for natural orifice transluminal endoscopic surgical procedures. Gastric peroral endoscopic myotomy appears to be safe and technically feasible in patients with benign gastric outlet obstruction in the remnant stomach after Roux-en-Y gastric bypass surgery. Larger studies are necessary to examine the long-term efficacy and safety of this procedure in this population with benign gastric outlet obstruction. Thank you very much for your attention.

gastric outlet obstruction

Roux-en-Y gastric bypass

endoscopic myotomy

stent placements

post-procedure improvement