If at first you don't succeed, the complicated course of an endoscopic reversal of a gastric bypass. A 41-year-old female with a distant history of an open Roux-en-Y gastric bypass that had required a complex surgical revision, represents several years later with abdominal pain, vomiting, and failure to thrive. The patient was taken to the operating room for reversal of her bypass, however this procedure was aborted due to significant adhesions as well as considerable bleeding requiring re-operation. Since that time, symptoms continued to progress. She underwent an upper endoscopy which was notable for stenosis of the gastrojejunal anastomosis as well as a marginal ulcer on the jejunal aspect. Serial through-the-scope balloon dilations were performed, however the patient had persistent symptoms and ultimately required enteral tube feeding. Her case was brought up at a multidisciplinary conference. Given inability to reverse her gastric bypass surgically, the decision was made to proceed with endoscopic reversal. An echoendoscope was advanced into the gastric pouch and the gastric remnant was identified. It was punctured with a 19-gauge needle and a mixture of contrast and saline was injected. A 20-by-10-millimeter lumen-opposing metal stent was then deployed under endosonographic and fluoroscopic guidance with the distal phalange in the gastric remnant and the proximal phalange in the gastric pouch. The rush of fluid through the lambs further confirmed its positioning. The stent was subsequently dilated with a hydrostatic balloon. At this point, significant bleeding was noted through the stent. This was treated with balloon tamponade, epinephrine injection, and hemospray, but no source could be identified. Placement of a coaxial covered metal stent was deferred due to the severity of bleeding and concern for impending hemodynamic instability, and the patient was sent to IR. Angiography revealed active arterial extravasation from a branch arising from the left gastric artery adjacent to the recently deployed lambs. Hemostasis was achieved via coil embolization with no further extravasation visualized on completion angiogram. The patient ultimately recovered, and completion of endoscopic reversal was performed by suturing the gastrojejunal anastomosis closed. Unfortunately, several weeks later, she developed worsening pain. Upper endoscopy noted a large ulcer base in the pouch, thought to be secondary to ischemia from the prior embolization. Repeat endoscopic suturing to over-sew the ulceration was performed. Gastrogastric double pigtail was placed to secure the lumen-opposing metal stent in place. Several months later, she presented with acute pain and vomiting. Upper endoscopy revealed that the lumen-opposing metal stent had migrated into the gastric remnant. The stent was retrieved and removed. There remained a patent gastrogastric fistulas tract. A longer, fully covered, self-expandable metal stent was placed over a guide wire and deployed across the gastrogastric fistula. It was then sutured in place. There was evidence of recurrent marginal ulceration, which was retreated with endoscopic suturing. The patient felt well for several months until she again presented with acute pain and obstructive symptoms. Repeat upper endoscopy revealed migration of the fully covered self-expandable metal stent. This stent was also removed. Given the chronicity and complete epithelialization of the tract, the decision was made not to replace the stent. The gastrointestinal anastomosis remained sutured shut. Repeat upper GI series demonstrated a patent gastrogastric fistula. This case highlights the complicated yet salvageable course of an endoscopic reversal of a Roux-en-Y gastric bypass for recalcitrant marginal ulcer after having failed surgical intervention. As demonstrated in this case, multiple stent placements as well as repeated endoscopic suturing may be required to achieve the successful outcome. Furthermore, should future surgical interventions be entertained, endoscopic management may provide temporization and nutritional optimization during a time at which operative options are suboptimal.

gastric bypass surgery

endoscopic procedures

balloon dilations

stent placements

gastrogastric fistula