Endoscopic ultrasound-guided gastroenterostomy to treat obstructive gastric twist after laparoscopic sleeve gastrectomy

Abstract

Figures

Diagnosis of the gastric twist after sleeve gastrectomy. a Twist of the stapling line. b Esophageal dilation and distal gastric obstruction confirmed with endoscopic contrast injection. c Gastric outlet obstruction due to the gastric twist.

Endoscopic and radiological imaging 3 months after endoscopic ultrasound-guided gastroenterostomy. a Contrast injection bypassing the gastric twist. b End-to-side gastroenterostomy with lumen-apposing metal stent.

Full text

Sleeve gastrectomy is the number one bariatric surgical intervention worldwide to treat morbid obesity. The rate of gastric stenosis after sleeve gastrectomy is around 2 to 4% 1 2 . A gastric twist represents a functional gastric stenosis. Endoscopic management with pneumatic dilation or stent is proposed as first-line therapy 1 2 3 . In case of failure, a surgical conversion to Roux-en-Y gastric bypass (RYGB) is performed. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using an oroenteric catheter is a new approach to treat a benign gastric outlet obstruction (GOO) 4 5 . We report the case of a patient with a gastric twist after laparoscopic sleeve gastrectomy successfully treated with EUS-GE after failure of repeat endoscopic dilatation.

A 69-year old woman underwent sleeve gastrectomy. One month later, she presented symptoms of GOO with a gastric outlet obstruction scoring system (GOOSS) score of 1. Endoscopy showed peptic esophagitis associated with a mid-gastric twist ( Fig. 1 a, b ) confirmed by computed tomography scan ( Fig. 1 c ). Three sessions of endoscopic dilatation were performed without clinical improvement. An EUS-GE was proposed to “bypass” the mid-gastric twist ( Video 1 ). An oroenteric catheter was placed over a guidewire to fill the jejunal lumen. Next, the target jejunal limb was identified by EUS and punctured with the electrocautery-enhanced lumen-apposing metal stent (LAMS) in pure cut mode. The LAMS was deployed connecting the gastric and jejunal lumen without adverse events. Clinical improvement with a GOOSS score of 3 was reported and confirmed by radiology and endoscopy at 1 and 3 months ( Fig. 2 a, b ).

Diagnosis of the gastric twist after sleeve gastrectomy. a Twist of the stapling line. b Esophageal dilation and distal gastric obstruction confirmed with endoscopic contrast injection. c Gastric outlet obstruction due to the gastric twist.

Endoscopic ultrasound-guided gastroenterostomy using wireless endoscopic simplified technique with oroenteric drain to treat gastric outlet obstruction due to gastric twist after sleeve gastrectomy.Video 1

Endoscopic and radiological imaging 3 months after endoscopic ultrasound-guided gastroenterostomy. a Contrast injection bypassing the gastric twist. b End-to-side gastroenterostomy with lumen-apposing metal stent.

The management of a gastric twist with clinical implications after sleeve gastrectomy is challenging. The improved technical and clinical success of EUS-GE has allowed it to be used in case of a benign GOO due to gastric twist. Moreover, EUS-GE avoided surgical conversion to RYGB. Future studies are needed to define what to do with the LAMS in case of benign gastric outlet obstruction: remove it, replace it, or leave it.

Endoscopy_UCTN_Code_TTT_1AS_2AK