A 44-year-old woman with Roux-en-Y gastric bypass and metastatic ovarian cancer status post-debulking surgery and cytoreductive therapy presented with severe left upper quadrant pain and nausea. Abdominal imaging demonstrated a large isolated fluid collection in the gastric remnant that was inaccessible via a percutaneous approach (A). Endoscopic placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the remnant stomach was performed. The distal and proximal ends of the stent were positioned inside the remnant stomach and gastric pouch, respectively (B). Her symptoms improved and the stent was removed 3 months later. One year later, her symptoms recurred. Repeat endoscopy demonstrated a patent gastrogastric fistula and fermenting partially digested food filling the remnant stomach. A second LAMS was placed to reconstitute dependent flow from the remnant stomach to the jejunum. Contrast was instilled into the gastric pouch and demonstrated flow from the gastric pouch into the gastric remnant, and through the newly placed LAMS into the jejunum (C). Two years later, her symptoms recurred. Repeat endoscopy revealed a stenosed gastrojejunal anastomosis (GJA). Entry through the existing gastrogastric fistula into the remnant stomach demonstrated that the previously placed remnant-jejunal LAMS contained a dissolved plastic coating, giving it the appearance of an uncovered metal stent with partial mucosal ingrowth (D). A new LAMS was placed into the GJA, reconstituting gastric bypass anatomy.
Footnotes
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Financial Disclosures: A. Schulman - has no personal or financial conflicts of interest to disclose. CC Thompson – Apollo Endosurgery, Inc. (Consultant/Research Support); Olympus (Consultant/Research Support); Boston Scientific (Consultant); Covidien (Consultant, Royalty, Stock).
Author Contributions:
Schulman AR: study concept and design; acquisition of data; drafting of the manuscript
Thompson CC: study concept and design; critical revision of the manuscript for important intellectual content;