S5193 Roux-en-Y Gastric Bypass Anatomy With Complete Obstruction at the Duodenal Bulb, Treated With Decompressive EUS-Guided LAMS Enterogastrostomy Into Efferent Limb

Introduction: Afferent loop syndrome, obstruction along the excluded stomach and duodenal limb, is an uncommon but emergent post-surgical complication of Roux-en-Y gastric bypass (RYGB). This syndrome commonly results from adhesions, foreign bodies, or strictures. It frequently requires surgical decompression or endoscopic management by removing obstructive foreign bodies or traversing and placing stents across areas of stenosis. Case Description: A 71-year-old woman with a distal history of RYGB presented for abdominal pain and was found to have computed tomography findings of a fluid-filled distended excluded stomach. The patient underwent laparotomy with gastric decompression, at which time complete duodenal bulb obstruction was noted, and a venting percutaneous endoscopic gastrostomy (PEG) tube was placed. Following an outpatient evaluation that included dedicated cross-sectional imaging, a decision was made to try to drain the stomach internally. She was originally evaluated with a percutaneous gastric endoscopy via gastro-cutaneous PEG fistula, which noted a complete stenosis and obstruction at the level of the duodenal bulb. Biopsies obtained from the stricture site were negative for malignancy. The patient subsequently underwent double balloon enteroscopy to evaluate the bilio-pancreatic limb, where again complete obstruction was noted and a stent was unable to be placed. Finally, the patient underwent endoscopic ultrasound (EUS). The efferent limb was adjacent to the excluded stomach. The stomach was filled with contrast via PEG. Enterogastrostomy was created using an electrocautery-enabled lumen-apposing metal stent (LAMS). The patient tolerated the procedure well and had her PEG removed with complete healing of her PEG site. She subsequently had an interval endoscopy revealing patent enterogastrostomy and underwent removal of LAMS and placement of permanent plastic pigtail stents to maintain the enterogastrostomy indefinitely. She has had no further complications. Discussion: This patient’s RYGB anatomy and degree of obstruction presented a clinical challenge and required an innovative interventional endoscopic approach that involved placement of a decompressive EUS-guided enterogastrostomy with LAMS using efferent jejunal limb. This case highlights EUS-guided enterogastrostomy as a treatment modality for obstructed afferent limbs with amenable anatomy.