Beware of the sandman! False “sand dollar sign” can be misleading during EUS-directed transgastric intervention in Roux-en-Y gastric bypass patients

Abstract

Patient 1, a 63-year-old woman with Roux-en-Y gastric bypass (RYGB) presented with upper abdominal pain. A CT scan showed gastric remnant wall thickening. An EUS-directed transgastric intervention (EDGI) was attempted, and the presumed excluded stomach was identified under endosonographic view by use of the “sand dollar sign” (A). However, a fluoroscopic view after injection of contrast material showed that the sand dollar sign was the descending colon (B). A repeated EUS evaluation of the true gastric remnant showed diffuse wall thickening (A), and EUS-FNA revealed gastric adenocarcinoma; thus, the sand dollar sign was deceptive. Sand dollar signGastrointestinal EndoscopyVol. 93Issue 2PreviewRegarding “Beware of the Sandman! False ‘sand dollar sign’ can be misleading during EUS-directed transgastric intervention in Roux-en-Y gastric bypass patients,”1 we agree that the sand dollar sign may not be uniformly visualized; however, any visual aid must be used concurrently with other data. Understanding relevant GI anatomy is paramount. In conventional Roux-en-Y gastric bypass, the stomach is divided, and a loop of jejunum is anastomosed to the gastric pouch. The gastric remnant maintains its anatomic position within the abdominal cavity and the gastric antrum, which gives rise to the sand dollar sign2 (Fig. 1), and remains close to midline in the area of the 11th or 12th rib (Fig. 2). Full-Text PDF