EUS-guided jejuno-jejunostomy with lumen-apposing metal stent for complete jejunal obstruction after gastric bypass

Abstract

Postoperative stenosis is a known adverse event of gastric bypass. We describe an EUS-guided technique for lumen-apposing metal stent (LAMS) placement to reconnect a completely obstructed jejunal Roux limb resulting from an adverse event during gastric bypass revision surgery with lysis of adhesions. Upper endoscopy showed a widely patent gastrojejunal anastomosis but revealed complete obstruction of the jejunum in the Roux limb, 3 cm distal to the gastrojejunostomy. EUS showed a jejunal segment beyond the blind end. EUS-guided needle puncture was performed through the jejunal obstruction (Video 1, available online at www.giejournal.org). A guidewire was advanced into the jejunum beyond the obstruction (Fig. 1). A 15-mm LAMS was placed under endoscopic, endosonographic, and fluoroscopic guidance. A CT scan the next day showed good flow of contrast medium from the stomach to the small bowel without leak. At 6 weeks, the LAMS was in a good position and was removed with a rat-toothed forceps. The jejunum was widely patent and was easily traversed after stent removal. At 3 months, an upper GI series showed no obstruction, and the patient was doing well clinically, tolerating solid foods and liquids. LAMS placement may be considered as an endoscopic option for treatment of postoperative complete jejunal obstruction.