S2175 Lumen-Apposing Metal Stents for Partial Reversal of Roux-en-Y Gastric Bypass: A Multicenter Study

Introduction: Roux-en-Y gastric bypass (RYGB) is an effective treatment of obesity, however, some patients will develop debilitating nutritional and metabolic post-operative complications requiring surgical reversal that can be technically challenging and highly morbid (up to 50%). Partial re-direction of food into the native stomach via GG fistula by LAMS may result in improvement of nutritional status and may serve either as a bridge to surgery or as definitive therapy. Methods: We report a prospective series of 16 patients with complications related to RYGB, from 4 tertiary care centers, who underwent EUS-guided LAMS placement and creation of a GG fistula due to either severe protein-calorie malnutrition, dumping syndrome, or postprandial hyperinsulinemic hypoglycemia. Results: Technical and clinical success was achieved in 16 patients (100%) and 15 patients (93.75%) respectively. Mean body mass index increased significantly from the time of placement of LAMS to mean follow-up of 15.8 months (range 3-62), 21.2 kg/m² to 24.4 kg/m², (Mean Difference (MD): 3.19, P = 0.005). In patients with benign disease, the mean change in % total body weight (TBW) was 13.4% at 3-6 month follow-up. Additionally, there was a significant increase in mean hemoglobin levels at follow-up, 10.4 g/dl to 11.6 g/dl, (MD: 1.22, P = 0.02). The mean serum albumin increased from a mean of 2.61 g/dl to 3.51 g/dl (MD: 0.89, P < 0.001) at 3 months. LAMS-related complications occurred in 3 patients and included pain, tissue ingrowth, and stent migration and all managed endoscopically. Conclusion: Our study supports the safety, feasibility, and efficacy of EUS-guided LAMS placement for partial reversal of RYGB. For patients with severe protein-calorie malnutrition or nutrient deficiency, creation of GG fistula via LAMS between the gastric pouch and the excluded stomach resulted in improvement in weight and various nutritional parameters due to diversion of chyme into the excluded stomach and duodenum, increasing the absorption and bioavailability of macro and micronutrients. In patients with dumping syndrome and post-prandial hypoglycemia, creation of a GG fistula via LAMS probably resulted in more controlled and lower-volume nutrient delivery into the afferent limb and thus significant clinical improvement in symptoms. EUS-guided LAMS placement is a safe, efficacious, and minimally invasive strategy for partial reversal of RYGB as either a bridge to definitive surgical reversal or as destination therapy.