Abstract
Endoscopic ultrasound-directed trans-gastric interventions (EDGI) using lumen apposing metal stent (LAMS) have been increasingly utilized in patients with Roux-en-Y gastric bypass surgery. We present a case of a 71-year-old woman with Roux-en-Y anatomy presenting with choledocholithiasis and enlarged retroperitoneal lymph nodes. Given inability to identify the excluded stomach on routine EUS, enteroscopy was performed with retrograde filling of the excluded stomach to allow for its localization on EUS. The patient underwent LAMS placement to create a jejuno-gastric anastomosis. Subsequently, she had an ERCP (via the LAMS) for removal of bile duct stone and an EUS with fine needle aspiration of the para-aortic lymph node (via the LAMS) confirming malignancy. The LAMS was removed after 2 weeks and the defect closed with APC and clips. An upper GI series obtained at 4 weeks did not show any residual leak. Patient continues to follow up with oncology for workup of primary malignancy.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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Madeline Seagle, Wencheng Li, and James Perumpillichira have no conflict of interest. Rishi Pawa is a consultant for Boston Scientific and Cook Medical.
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Key points
1. Access to the excluded gut after Roux-en-Y gastric bypass surgery for management f luminal and extraluminal diseases around the gastric remnant and the duodenum can be safely achieved with EUS-guided placement of LAMS between the gastric pouch or Roux limb and the excluded stomach.
2. In most patients, the excluded stomach can be visualized on endoscopic ultrasound with the echoendoscope positioned in the gastric pouch or the Roux limb.
3. Enteroscopy-assisted retrograde filling of the excluded stomach with dilute contrast can facilitate visualization of the remnant stomach in difficult cases.
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Seagle, M., Li, W., Perumpillichira, J. et al. Enteroscopy-Assisted EUS-Guided Trans-gastric Intervention After Roux-en-Y Gastric Bypass Surgery. OBES SURG 34, 291–292 (2024). https://doi.org/10.1007/s11695-023-06931-6
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DOI: https://doi.org/10.1007/s11695-023-06931-6