Endoscopic ultrasound–assisted double–lumen-apposing metal stent septotomy for permanent partial reversal of Roux-en-Y gastric bypass

Abstract

Background and Aims

Surgical reversal of Roux-en-Y gastric bypass (RYGB) is associated with high morbidity but may be necessary in patients with malnutrition. In recent years, endoscopic gastrogastric (GG) fistulas created via lumen-apposing metal stents (LAMSs) have offered patients a less-invasive alternative, but they are associated with adverse events if left in situ for long periods of time. We describe the use of a double-LAMS septotomy technique with septotomy to achieve permanent and durable partial RYGB reversal.

Methods

A 39-year-old man with severe malnutrition (body mass index [BMI] 18.4 kg/m²) underwent an EUS-guided placement of 2 parallel GG LAMSs. Six weeks later, both LAMSs were removed, and the septum between the 2 GG fistulas was dissected using an insulated-tip knife.

Results

There were no intraprocedural or postprocedural adverse events. The patient was discharged on a liquid diet and transitioned to a regular solid diet. He maintained weight gain (BMI 28 kg/m²) on clinical follow-up.

Conclusions

EUS-guided double-LAMS septotomy is safe, minimally invasive, and durable for partial permanent reversal of RYGB in high-risk patients.

Background

Roux-en-Y gastric bypass (RYGB) is a highly durable and metabolically impactful intervention. A small proportion of patients (up to 2.3%), however, experience debilitating adverse events such as severe protein calorie malnutrition, refractory dumping syndrome, and refractory postprandial hyperinsulinemic hypoglycemia, and require surgical reversal of the bypass. Traditional reversal surgery is technically demanding and highly morbid, with up to 35% of patients developing perioperative adverse events.^1,2

In recent years, lumen-apposing metal stents (LAMSs) have been used to create stable gastrogastric (GG) fistulas to facilitate endoscopic retrograde cholangiopancreatography in patients with RYGB. GG fistulas, once created, allow for ingested food to be partially shunted into the excluded stomach, facilitating absorption of nutrients and resulting in weight gain.

EUS-guided partial reversal of RYGB via LAMSs provides a minimally invasive alternative to surgical reversal, especially for patients who are deemed high risk to undergo an operation. Prolonged LAMS dwell time is associated with tissue ingrowth, migration, and peptic ulceration, prompting LAMS removal.^3,4 Unfortunately, most GG fistulas close spontaneously after the LAMS is removed. Therefore, there is an urgent need to develop a reliable technique to consolidate GG anastomoses after LAMS removal (Fig. 1).

Figure 1.

Illustration demonstrating step 1 of the EUS-assisted double-LAMS septotomy procedure for permanent partial reversal of Roux-en-Y gastric bypass. Note the partial reversal of Roux-en-Y anatomy using 2 LAMSs. LAMS, Lumen-apposing metal stent.

Case presentation

A 39-year-old man with a history of RYGB was referred with severe malnutrition (body mass index [BMI] of 18.4 kg/m²). Considering his poor surgical candidacy, it was decided to place a 20- × 10-mm GG LAMS to partially reverse the patient's bypass. After a good response to the LAMS placement and an increase in BMI to 28 kg/m², the patient decided not to undergo complete RYGB surgical reversal. After a multidisciplinary discussion, we proceeded with endoscopic consolidation of the GG fistula using a previously described technique.⁵

Endoscopic methods

EUS-assisted partial reversal of the RYGB was performed using the following 2-step procedure (Figs. 1 and 2). During the first step, using EUS, we placed a second cautery-enhanced 20- × 10-mm LAMS transmurally from the gastric pouch into the excluded stomach at approximately 2 cm from the previously placed LAMS (Fig. 3). This resulted in creation of a 2- to 3-cm tissue bridge between the 2 LAMSs. The patient was started on a regular diet and discharged home the same day with 2 LAMSs in situ (Fig. 4). Six weeks later, the patient underwent a scheduled second procedure. After removal of both LAMSs, the tissue bridge was examined using EUS and revealed no significant vessels or intervening organ structures (Figs. 5 and 6). A soft-tip 0.035-inch angled guidewire (Jagwire; Boston Scientific, Marlborough, Mass, USA) was passed through one of the GG fistulas and withdrawn from the other to create a loop. The loop was used for tissue traction and to guide the plane of dissection during septotomy (Fig. 7). Using an insulated-tip knife (ITknife2 electrosurgical knife, Olympus, Center Valley, Pa, USA), we dissected the tissue bridge completely (Fig. 8). No significant bleeding was encountered. After completion, water-soluble contrast was injected into the gastric pouch and flowed into the excluded stomach with no extravasation (Video 1, available online at www.videogie.org). The patient was admitted overnight for observation and started on a liquid diet for 3 days. No adverse events were encountered. On clinic follow-up, the patient was tolerating a diet, and his weight remained stable.

Figure 2.

Illustration demonstrating step 2 of the EUS-assisted double-LAMS septotomy procedure for permanent partial reversal of Roux-en-Y gastric bypass. Note the significantly larger GG anastomosis that results from complete takedown of the septum. GG, Gastrogastric; LAMS, lumen-apposing metal stent.

Figure 3.

Endoscopic image demonstrating placement of a “hot” or cautery-enhanced lumen-apposing metal stent (LAMS), approximately 2 cm from the first LAMS.

Figure 4.

Endoscopic image demonstrating 2 adjacent lumen-apposing metal stents.

Figure 5.

Endoscopic image demonstrating a mature septum (arrow) between 2 gastrogastric fistulas, after removal of both lumen-apposing metal stents.

Figure 6.

Endosonographic image, demonstrating 2 well-formed fistula tracts (purple arrows) between the gastric pouch and excluded stomach.

Figure 7.

Endoscopic image demonstrating a septotomy using an insulated-tip knife. Note the use of a wire loop to guide the plane of dissection (green line).

Figure 8.

Endoscopy (A) and fluoroscopy images (B) after successful dissection of the septum. Note the significantly enlarged gastrogastric (G-G) anastomosis with unrestricted (black arrow) passage of contrast from the gastric pouch to the afferent limb.

Conclusions

EUS-guided double-LAMS septotomy is a technically feasible novel procedure that converts a stent-dependent GG fistula into a durable anastomosis without prolonged stent dwell or high-risk surgery. In our patient, it preserved weight gain while avoiding LAMS-related adverse events such as tissue ingrowth and stent migration, achieving safe permanent partial reversal of RYGB with no adverse events. Larger prospective studies are needed to evaluate safety, efficacy, durability, and long-term benefits.

Patient Consent

Written informed consent for the procedure was obtained from all patients. Clinical data were collected prospectively under an Institutional Review Board–approved study protocol.

Disclosure

The following author disclosed financial relationships: S. Irani: Consultant for Boston Scientific and Gore Medical. K. Kadkhodayan disclosed no financial relationships.

Supplementary data

Video 1

Description of EUS-assisted double-LAMS septotomy for permanent partial reversal of Roux-en-Y gastric bypass. LAMS, Lumen-apposing metal stents.