Endoscopic Ultrasound Guided Gastro-Gastrostomy for Reversal of Roux-en-Y Gastric Bypass to Facilitate Weight Gain

Introduction: While the initial intention of Roux-en-Y Gastric Bypass (RYGB) is to lose weight, surgical complications, such as GJ stricture, can pose a threat to a patient’s nutrition. Endoscopic reversal of the RYGB can be achieved through fistulation of the gastric pouch and remnant stomach through gastro-gastrostomy via lumen-apposing metal stent (LAMS). In this case, we present a permanent endoscopic reversal of RYGB through gastro-gastrostomy for nutritional supplementation in a patient with debilitating gastrojejunal (GJ) stricture and failure to gain weight from her RYGB. Case Description/Methods: A 77-year-old woman with history of RYGB 25 plus years ago complicated by GJ stricture, presents for undesired progressive weight loss. Since her RYGB, the patient had developed progressive dysphagia and regurgitation requiring serial EGD dilations every 2 to 3 months. Despite the dilations, the patient’s weight went from 120 lbs to 104 lbs over 8 months. Evaluation with EGD confirmed a 5 cm gastric pouch and a 6 mm GJ anastomotic stenosis that could be traversed with moderate difficulty (Figure 1A). Utilizing EUS guidance within the gastric pouch, the native gastric body was located and using FNA needle was infused with a methylene blue-saline solution. A 10 mm x 20 mm hot LAMS was then used to puncture the gastric pouch and then deployed to form a gastro-gastrostomy with adequate drainage of the methylene blue solution (Figure 1B). Evaluation of the native stomach through the LAMS revealed normal mucosa and anatomy. On subsequent follow-up visits, the patient reported improvement of her dysphagia with a weight gain up to 140 lbs. Discussion: GJ stenosis in RYGB can be seen in 3%-27% of cases, leading to dysphagia, regurgitation, and unwanted severe weight loss and malnutrition. While balloon dilation is the mainstay treatment for GJ stenosis, serial dilation can be taxing to patients and can pose a risk for perforation. Furthermore, persistent weight loss and dysphagia despite serial dilations should prompt endoscopic evaluation for neoplasm. Given the altered anatomy in RYGB patients, endoscopic ultrasound guided gastro-gastrostomy via LAMS can offer a non-invasive measure to permanently reverse a RYGB for nutritional support, reduce the symptoms associated with a GJ stricture, and to evaluate the native stomach, duodenum, and CBD for alternate causes of weight loss.Figure 1.: A) 5 cm gastric pouch with a 6 mm GJ anastomotic stenosis that could be traversed with moderate difficulty. B) Drainage of methylene blue-saline solution after successful deployment of LAMS to form a gastro-gastrostomy between the gastric pouch and gastric remnant.