2123 The Vanishing Gastrojejunostomy: A Case Report

Abstract

INTRODUCTION: Gastrojejunal anastomotic strictures or stenoses are well recognized complications from Roux-en-Y gastric bypass surgery. Endoscopy remains an effective and safe means to diagnose these complications, which can occur as early as one month after surgery. The two main treatment modalities include endoscopy, either with balloon or bouginage dilators, or open versus laparoscopic surgery. Despite direct visualization, endoscopy could easily miss a severely stenotic anastomosis, as illustrated in the case of our a patient with gastrojejunal stenosis status post gastric bypass surgery. CASE DESCRIPTION/METHODS: 43-year-old man with past medical history of morbid obesity s/p laparoscopic Roux-en-Y was admitted for acute nausea and vomiting. The Rouz-en-Y was performed one month ago and he initially was doing well with expected weight loss. Over the last 10 days, he had persistent nausea, vomiting, and anorexia. Labs were unremarkable at presentation. Initially, the surgical team was consulted and performed an EGD which revealed severe stenosis at the gastrojejunal anastomosis site; a balloon dilator was not able to be passed through the stenosis. The following day, gastroenterology team performed a repeat EGD, which revealed a large hematoma in the gastric body and epinephrine was injected. Initially, the gastrojejunal anastomosis was not clearly visualized despite partial dislodgement of the clot. However, under fluoroscopy, a closed, possible anastomotic site was identified and a wire was advanced through with contrast injection for verification that the wire was in fact in the bowel lumen. The anastomosis was then dilated and an AXIOS stent was placed across the anastomosis. The patient recovered well post-operatively, tolerating PO intake and was discharged. At follow up, the stent was successfully removed via rat-toothed forceps without complication. The anastomotic site was friable, but was wide open and a standard gastroscope was easily advanced through without complications. DISCUSSION: Gastrojejunal anastomotic stenosis is a known complication of Roux-en-Y gastric bypass surgeries. Its etiology is not completely understood and likely multifactorial but treatment options include endoscopic dilation and surgery. For our patient, fluoroscopic guidance with wire placement through the anastomotic site was required for successful deployment of the AXIOS stent. Therefore, endoscopic diagnosis should be considered as a safe modality for diagnosis and intervention for these complications.