Endoscopic reversal of a duodenal switch. These are our disclosures. Biliopancreatic diversion, also known as duodenal switch, is a bariatric surgery that includes sleeve gastrectomy and a long Roux-en-Y intestinal bypass. In case of severe malnutrition, surgical reversal can be done by creating a proximal anastomosis between the alimentary and the biliopancreatic limbs. To our knowledge, endoscopic reversal of the duodenal switch has not been reported previously. This is a schematic representation of the biliopancreatic diversion surgery. The anastomosis between the alimentary and the biliopancreatic limb is very distal, resulting in the bypass of two-thirds or more of the intestine. Hence, the nutrients have a lower absorption area. Furthermore, the biliopancreatic secretions and enzymes are separated from the nutrients for most of the intestine, leading therefore to their reduced digestion. This is the case of a 43-year-old female with past surgical history of biliopancreatic diversion who was hospitalized for diarrhea, malnourishment, and significant weight loss. Numerous evaluations for nephlasia were negative. It was therefore deemed that the patient's malnourishment and weight loss were due to her altered anatomy. Considering the general conditions of the patient, endoscopic reversal of the biliopancreatic diversion was offered as a minimally invasive alternative to surgery. The endoscopic procedure was performed in an endoscopy unit under general anesthesia. The patient received intravenous antibiotics immediately prior to the procedures. The first step was to explore the anatomy of the patient, both endoscopically and fluoroscopically. This is the typical shape of the stomach after sleeve gastrectomy. The gastrointestinal anastomosis was patterned. We then proceeded to explore the alimentary limb, the only one that we can access for now endoscopically. Fluoroscopically, we confirmed that we were in the alimentary limb, however, we did not inject contrast in order to avoid confusion with the biliopancreatic limbs afterwards. We are now ready to proceed to endoscopic reversal of the duodenal switch. Schematically, it can be represented in the following way. Endoscopic duodenal switch reversal consists in the recreating the physiological continuity between the biliopancreatic limb and the alimentary limb by placement of a lumen-opposing metal stand. This has the advantage of allowing nutrients to mix early on with the biliopancreatic secretions and enzymes, and also increases the absorption area since nutrients can now have access to both alimentary and biliopancreatic limbs. We can now proceed to show the procedure. First, we identify the biliopancreatic limb from the alimentary limb using endoscopic ultrasound. This is done first under endoscopic guidance by positioning the linear echoendoscope towards the right upper quadrant, where we expect to find the duodenal stump and the biliopancreatic limb. Then, with endoscopic ultrasound, we are able to identify the collapsed small bowel loop in the right upper quadrant. After excluding and deposing vessels, we access the small bowel loop with a flexible 19-gauge FNA needle. We then perform a test injection with small quantities of contrast to make sure that we are in the lumen and not in the intestinal wall, thus to avoid doing intramural injection. Once we confirm that we are inside the lumen, we proceed to infuse more contrast by placing a pump into the FNA needle. A glucose glucagon was given to slow the peristalsis of the biliopancreatic limb and aid in fluid retention. Once the biliopancreatic limb was clearly defined and distended, we can then proceed to the creation of the jejunotudeanostomy. We use a freehand technique by direct deployment of a counter-enhanced lumen opposing metal stance from the alimentary limb to the biliopancreatic limb under EOS guidance. A 20 mm in diameter and 10 mm in length lumen opposing metal stand was inserted directly across the alimentary limb into the biliopancreatic limb. We do not use a wire because of the risk of pushing the small bowel away. The internal flange was first released under EOS guidance and pulled up. This then was followed by the release of the second flange under endoscopic vision, creating thus the jejunotudeanostomy. At fluoroscopic evaluation, contrast was able to pass from both ways across the lumenopause in metal stands, and there was no sign of perforation. We then proceeded to place a percutaneous endoscopic jejunostomy close to the lumenopause in metal stand to allow the passage of the food both in the alimentary limb and in the biliopancreatic limb. After choosing the appropriate site with percutaneous trace illumination, the needle-cannula assembly was passed through the abdominal wall into the alimentary limb. Then a snare device was used to take the wire and therefore put the badge. Follow-up endoscopy after two months was done because the patient had gained weight and therefore the percutaneous jejunostomy was removed. The jejunotodenostomy was still in place and was patent. Currently the patient still has the stand in place six months from the procedure and is doing well. In conclusion, we report that endoscopic reversal of a biliopancreatic diversion by means of a lumenopause in metal stand is feasible. It can be considered a minimally invasive alternative to surgery which can potentially improve on morbidity, mortality, and cost. Larger studies are warranted to explore the long-term outcomes of endoscopic approach compared to surgery.

endoscopic reversal

biliopancreatic diversion

duodenal switch

proximal anastomosis

endoscopic procedure