Gastrojejunostomy Research Articles

Resizing of the Gastric Pouch for Weight Regain after Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: Is It a Valid Option?

The laparoscopic resizing of the gastric pouch (LPR) has recently been proposed as a revisional technique in the case of weight regain (WR) after gastric bypass procedures. The aim of this study was to report our experience with LPR for WR. All patients with WR ≥ 25% after gastric bypass and with a dilated gastric pouch and/or gastrojejunal anastomosis who underwent LPR between January 2017 and January 2022 were retrospectively reviewed. From a radiological point of view, a gastric pouch was considered dilated when its volume was calculated at >80 cm3 for LRYGB and >200 cm3 for OAGB upon a 3D-CT scan. The endoscopic criterion considered both the diameter of the gastrojejunal anastomosis and the gastric pouch volume. All anastomoses > 20 mm for LRYGB and >40 mm for OAGB were considered dilated, while a gastric pouch was considered endoscopically dilated when the retrovision maneuver with the gastroscope was easily performed. These selection criteria were arbitrarily established on the basis of both our personal experience and literature data. Twenty-three patients had LPR after a Roux-en-Y gastric bypass or one-anastomosis gastric bypass. The mean BMI at LPR was 36.3 ± 4.7 kg/m2. All patients underwent LPR, while the resizing of the GJA was also performed in 3/23 (13%) cases, and hiatoplasty was associated with the resizing of the pouch in 6/23 cases (26.1%). The mean BMI at the last follow-up was 29.3 ± 5.8 kg/m2. The difference between the BMI before resizing and the BMI at the last follow-up visit was statistically significant (p = 0.00005). The mean %TWL at 24.2 ± 16.1 months was 19.6 ± 9%. Comorbidities had an overall resolution and/or improvement rate of 47%. The mean operative time was 71.7 ± 21.9 min. The conversion rate was nil. Postoperative complications occurred in two cases (8.7%). In our series, LPR for WR showed good results in weight loss and in improvement/resolution of comorbidities, with an acceptable complication rate and operative time. Only further studies with a greater cohort of patients and a longer postoperative follow-up will be able to highlight the long-term benefits of this technique.

Gastrojejunostomy versus endoscopic duodenal stent placement for gastric outlet obstruction in patients with unresectable pancreatic cancer: a propensity score-matched analysis.

Treatments for patients with gastric outlet obstruction (GOO) due to unresectable pancreatic cancers (URPC) include gastrojejunostomy (GJJ) and endoscopic duodenal stent placement (EDSP). This study compared the efficacy and safety of GJJ and EDSP in patients with GOO due to URPC. This study retrospectively evaluated consecutive patients with GOO due to URPC who underwent GJJ or EDSP between April 2016 and March 2020. The efficacy and safety of GJJ and EDSP were compared with propensity score analysis. Subgroup analyses of overall survival (OS) were compared after propensity matching. Data were obtained from 54 patients who underwent GJJ and from 73 who underwent EDSP at five tertiary care hospitals. After propensity matching, OS was significantly longer in patients who underwent GJJ than EDSP (110 vs. 63days, respectively; p = 0.019). Evaluation of long-term adverse events showed that the frequency of cholangitis and obstructive jaundice was significantly lower in the matched GJJ than in the matched EDSP group (p = 0.012). Subgroup analyses showed that OS in patients with good performance status (PS; p = 0.041), biliary obstruction (p = 0.007), and duodenal obstruction near the papilla (p = 0.027), and those receiving chemotherapy (p = 0.010), was significantly longer in the matched GJJ group than in matched EDSP group. GJJ provides longer OS than EDSP for patients with GOO caused by URPC, especially for patients with good PS, biliary obstruction, and duodenal obstruction near the papilla, and those receiving chemotherapy.

Comparing the Effectiveness of Different Types of Revisional Bariatric Surgery on Weight Loss

INTRODUCTION: Although Roux-en-Y gastric bypass (RYGB) is one of the most effective weight loss operations, 10% to 35% of patients fail to lose weight. This population may benefit from revisional operation; however, no standardized approach currently exists. This study examines weight loss after various methods of RYGB revisional operation. METHODS: MBSAQIP and retrospective chart review were used to identify patients who underwent revisional RYGB operation at a single, high-volume institution between 2014 and 2021. Revisional procedures were categorized as gastric pouch and/or gastrojejunal anastomosis revision (PAR), distalization of jejunojejunal anastomosis only (DJA), or pouch/GJA revision and distalization (PAD). Demographics, preoperative comorbidity, weight loss, and 30-day complication were compared among groups. RESULTS: A total of 193 patients underwent revisional bariatric surgery due to insufficient weight loss. Of these, 138 (71.5%) underwent PAR, 8 (4.15%) had DJA, and 47 (24.35%) had PAD. No significant differences were found in sociodemographic factors; preoperative weight, BMI, or comorbidity; and 30-day postoperative complication, emergency department visits, and readmission rate. All 3 methods have led to a statistically significant decrease in BMI (p < 0.0001 for PAR and PAD, p = 0.001 for DJA) and weight (p < 0.0001 for PAR and PAD, p = 0.002 for DJA), but there were no significant differences in excess BMI and weight loss among the 3 methods (Table 1). Table 1. - Comparing Preoperative Measurements and Postoperative Outcomes among 3 RYGB Revision Procedures Characteristic Pouch and/or GJA resizing (PAR) Distalization only (DJA) Pouch/GJA resizing and distalization (PAD) p Value Preoperative BMI (kg/m2) 43.15 (SD = 7.59) 44.57 (SD = 4.90) 43.67 (SD = 6.13) 0.807 Current BMI (kg/m2) 39.6 (SD = 11.1) 39.3 (SD = 4.3) 39.0 (SD = 7.9) 0.937 Preoperative weight (kg) 116.0 (SD = 24.0) 116.7 (SD = 16.7) 117.2 (SD = 18.9) 0.945 Current weight (kg) 104.4 (SD = 22.9) 104.3 (SD = 13.6) 100.7 (SD = 19.2) 0.596 Emergency department visits within 30 days postoperatively 6 (4.35%) 0 (0%) 2 (4.26%) 0.225 Readmission within 30 days postoperatively 9 (6.5%) 9 (6.5%) 3 (6.38%) 0.490 Excess BMI loss (%) 28.5 (SD = 68.2) 26.8 (SD = 12.7) 25.5 (SD = 30) 0.956 Weight loss (%) 8.75 (SD = 17) 10.4 (SD = 5.5) 13.5 (SD = 12.5) 0.205 Length of stay (days) 1.7 (SD = 0.9) 1.3 (SD = 0.5) 1.5 (S D= 0.8) 0.175 CONCLUSION: Revisional bariatric surgery is effective in leading to weight loss, but there is no significant difference in the effectiveness of the 3 methods. We plan to compare the 3 methods in terms of long-term complication and resolution of comorbidity.

Digestive tract reconstruction in pancreaticoduodenectomy in University Hospitals of China: a national questionnaire survey

Background: Pancreaticoduodenectomy (PD) has been widely applied in general hospitals in China; however, there is still a lack of unified standards for each surgical technique and procedure. This survey is intended to investigate the current status of digestive tract reconstruction after PD in university hospitals in China. Method: A cross-sectional survey was conducted among the members of the Young Elite Pancreatic Surgery Club of China by using the Questionnaire for Digestive Tract Reconstruction after Pancreaticoduodenectomy. The questionnaire was disseminated and collected by point-to-point communication via WeChat public platforms. Results: A total of 73 valid questionnaires were returned from 65 university hospitals in 28 provincial divisions of mainland China. The respondents who performed PD surgery with an annual volume of over 100 cases accounted for 63%. Generally, laparoscopic PD was performed less often than open PD. Child and Whipple reconstructions accounted for 70% and 26%, respectively. The sequence of pancreatoenteric, biliary-enteric, and gastrointestinal reconstruction accounted for 84% of cases. In pancreatoenteric anastomosis, double-layer anastomosis is the most commonly employed type, accounting for approximately 67%, while single-layer anastomosis accounts for 30%. Of the double-layer anastomoses, duct-to-mucosa/dunking (94%/4%) pancreatojejunostomy was performed with duct-mucosa using the Blumgart method (39%) and Cattel-Warren (29%), with continuous/interrupted sutures in the inner layer (69%/31%) and continuous/interrupted sutures in the outer layer (53%/23%). In single-layer anastomosis, continuous/interrupted sutures accounted for 41%/45%. In hepatojejunostomy, single-layer/double-layer suture accounted for 79%/4%, and continuous/interrupted suture accounted for 75%/9%. Forty-six percent of the responding units had not applied double-layer biliary-intestinal anastomosis in the last 3 years, 75% of the responding surgeons chose the anastomosis method according to bile duct diameter, with absorbable/non-absorbable suture accounting for 86%/12%. PD/pylorus-preserving PD accounted for 79%/11% of gastrojejunostomy (GJ) cases, the distance between GJ and hepaticojejunostomy &lt; 30, 30–50, and &gt; 50 cm were 11%, 75%, and 14%, respectively. Antecolic/retrocolic GJ accounted for 71%/23% of cases. Twenty-two percent of GJ cases employed Braun anastomosis, while 55% and 19% of GJ cases used linear cutting staplers/tube-type staplers, respectively; 60%/14% were reinforced/not reinforced via manual suturing after stapler anastomosis. Manual anastomosis in GJ surgery employed absorbable/non-absorbable sutures (91%/9%). Significant differences in reconstruction techniques were detected between different volumes of PD procedures (&lt;100/year and &gt;100/year), regions with different economic development levels, and between north and south China. Conclusion: Digestive tract reconstruction following PD exists heterogeneity in Chinese university hospitals. Corresponding prospective clinical studies are needed to determine the consensus on pancreatic surgery that meets the clinical reality in China.

Weighted Tip Extensions Result in Fewer Gastrojejunostomy Tube Migrations and Increase Tube Lifespan

PurposeTo investigate the safety and efficacy of attaching a weighted extension to the distal aspect of prefabricated gastrojejunostomy (GJ) tubes, and to determine whether this alteration reduces the occurrences of tip reflux into the esophagus or stomach. Materials and MethodsThis retrospective 1-way crossover study included 64 GJ tubes in 15 patients placed by multiple operators in the interventional radiology department at a single institution from July 1, 2019, to December 1, 2021. Patients were selected for a weighted tip extension if they required a GJ tube exchange because of the distal tip refluxing into the stomach or esophagus and were aged ≥18 years. These modified GJ tubes were prepared by cutting the distal end of a nasojejunal tube to a length of 10–15 cm and suturing to the distal aspect of the GJ tube. ResultsOf the 64 tubes studied, 37 had a weighted tip extension. The unmodified GJ tubes had a mean lifespan of 34.3 days, which was significantly shorter than the weighted tips (92.8 days; t test P = .001). There was 1 limited adverse event of abdominal pain and spasms that resolved after exchange with a shorter weighted extension. ConclusionsThis study suggests that for patients who require a GJ tube replacement because of the tip refluxing proximally into the stomach or esophagus, the addition of a 10–15-cm weighted extension to the distal end of the GJ tube is safe and significantly improves the lifespan of the enteric tube.

Weight Recidivism and Dumping Syndrome after Roux-En-Y Gastric Bypass: Exploring the Therapeutic Role of Transoral Outlet Reduction.

Obesity is a chronic, relapsing disease representing a global epidemic. To date, bariatric surgery is the most effective treatment for morbid obesity in the long-term. Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric interventions, with excellent long-term outcomes. However, about one-third of patients may experience weight regain over time, as well as dumping syndrome. Both these conditions are challenging to manage and require a multidisciplinary and personalized approach. The dilation of the gastro-jejunal anastomosis is a recognized etiological factor for both weight regain and dumping syndrome. Dietary modifications, behavioral interventions, and medications represent the first therapeutic step. Revisional surgery is the traditional approach when non-invasive treatments fail. However, re-interventions may be technically difficult and are associated with increased morbidity and mortality. Transoral outlet reduction (TORe) is an endoscopic procedure aimed at reducing the size of the anastomosis and is proposed as a minimally invasive treatment of weight regain and/or dumping syndrome refractory to conservative therapies. This review is aimed at providing a narrative overview of the role of TORe as part of the multidisciplinary therapeutic toolkit nowadays available to approach weight regain and dumping syndrome after RYGB.

Enterotomy Closure after Minimally Invasive Distal Gastrectomy with Intracorporeal Anastomosis: A Multicentric Study

Introduction: Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis. Methods: All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread. Results: Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029). Conclusions: Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.

S2871 Successful Treatment of “Candy Cane” Syndrome Through Endoscopic Gastrojejunal Anastomosis Revision

Introduction: “Candy cane” syndrome is a post-surgical Roux-en-Y gastric bypass (RYGB) complication associated with a markedly long, surgically-created blind end of the afferent Roux limb distal to the gastrojejunostomy. Gradual filling of this long blind limb with food can result in symptoms, including postprandial epigastric pain, nausea, vomiting, or regurgitation. Treatment of candy cane syndrome traditionally consists of laparoscopic resection of the redundant blind afferent limb. We present the first case of successful treatment of candy cane syndrome through endoscopic revision of the gastrojejunal (GJ) anastomosis. Case Description/Methods: A 40-year-old female presented for evaluation of intractable acid reflux, nausea, and weight recidivism eight years post RYGB. Esophagogastroduodenoscopy revealed evidence of prior RYGB, a healthy-appearing GJ anastomosis, a direct path across the GJ anastomosis into the blind afferent limb, and the enteral efferent limb located at a more angulated orientation toward the 4:00 position. An upper gastrointestinal series revealed an exaggerated blind afferent limb with pooling of contrast in the afferent blind limb before spilling to progress down the Roux limb. This finding suggested the reflux likely stemmed from the excessively long blind afferent limb. The patient wished to avoid surgery and a novel endoscopic suturing technique was performed that narrowed the GJ anastomosis and oriented flow towards the enteral efferent limb. This resulted in 1) limiting acid reflux 2) assisting with weight loss and 3) redirecting flow of contents more toward the enteral efferent limb. Post-procedure our patient had no additional weight gain and her acid reflux and nausea resolved. (Figure) Discussion: Candy cane syndrome is an underappreciated complication reported following RYGB. It results from an excessively long blind afferent Roux limb at the gastrojejunostomy that can lead to food accumulation. Patients often present with nausea, vomiting, food intolerance, acid reflux, and abdominal pain. Many patients remain undiagnosed due to vague gastrointestinal symptoms, delayed presentation, and physician unawareness. Historically, treatment has required surgical revision. Endoscopic suturing revision of the GJ anastomosis can provide an alternative less invasive and possibly safer treatment option that address the reflux symptoms, weight regain, and aberrant flow of contents into the blind limb.Figure 1.: Figure: Endoscopic view of direct access into the blind afferent limb A, the acute angle of the enteral efferent limb B, and dilated gastrojejunal anastomosis C.

S2891 A Case of Endoscopic Ultrasound-Guided Gastrojejunostomy for Gastric Outlet Obstruction in a Patient With a Migrated FCSEMS

Introduction: Fully covered self-expandable metal stents (FCSEMS) are often used to resolve benign strictures causing gastric outlet obstruction (GOO). With a short length and anti-migration waist, the TaeWoong Medical FCSEMS is designed to produce radial force against the stricture and greatly reduce stent migration. We report the case of a patient with a retroperitoneal hematoma causing GOO secondary to a duodenal stricture. The FCSEMS placed across the stricture was complicated by stent migration to the stomach, and a gastrojejunostomy (GJ) was performed using a lumen-apposing metal stent (LAMS) and LAMS dilation. Case Description/Methods: A 47-year-old man with no significant history was admitted for GOO secondary to spontaneous non-traumatic hemorrhagic retroperitoneal bleeding. He presented with recurrent episodes of acute epigastric pain radiating to his back, nausea, and vomiting and was found to have pancreatitis with an elevated lipase of 661. Computed tomography (CT) showed a retroperitoneal hematoma surrounding a severely thickened descending and proximal duodenum and the head of the pancreas. Marked distention of the stomach was consistent with GOO. The patient was evaluated by the gastroenterology service, and an esophagogastroduodenoscopy (EGD) revealed a stricture involving the distal D2 and proximal D3 that could not be traversed with the endoscope. An 18 mm x 140mm FCSEMS was placed across the stricture and secured to the antral wall. Three days after discharge, he developed a recurrence of symptoms after advancing his diet to solids. Repeat x-ray and an endoscopic ultrasound (EUS) guided EGD showed the complete migration of the duodenal FCSEMS into the stomach (Panels 1 and 2). The FCSEMS was removed using rat-toothed forceps and an EUS GJ was performed using a 20 mm x 10 mm cautery enhanced LAMS (Panel 3). The patient was able to tolerate both solids and liquids before discharge. Discussion: Despite previously reported benefits of stent anchoring and favorable outcomes of the TaeWoong FCSEMS design, migration occurred. GJ to relieve GOO has emerged as an alternative to refractory cases of endoscopic stenting or surgical GJ, with lower reintervention rates. The use of LAMS to create a GJ successfully mitigated the obstruction in this patient with a complicated hospital course. EUS GJ to relieve obstruction has shown to be promising, and continued research on its safety and efficacy compared to standard therapies (namely FCSEMS) is merited.Figure 1.: 1) X-ray abdomen and pelvis showing the migrated duodenal stent. 2) - Endoscopic view of the migrated FCSEMS in the stomach. 3) - Endoscopic view of the fully deployed LAMS showing the anastomotic connection between the stomach and jejunum, bypassing the duodenal stricture.

S3691 Where Is the Bumper? A Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube Malfunction

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are used for enteral access in patients requiring nutritional support. PEG tube placement and removal generally are regarded as safe procedures. However, complications can be experienced in 16-70%, ranging from benign pneumoperitoneum to gastric outlet obstruction, buried bumper syndrome, and bowel perforation. Our case describes a retained internal bumper during PEG tube removal that undergoes spontaneous passage. Case Description/Methods: Our patient is a 71-year-old male with a past medical history of tongue cancer treated with chemoradiation and subsequent dysphagia due to esophageal strictures necessitating PEG tube placement. He presented to the hospital with nausea, recurrent emesis, and an inability to tolerate tube feeds. His PEG tube was placed to gravity with one liter of output and relief of symptoms. A plan was made to proceed with gastrojejunostomy (G-J) tube to mitigate his symptoms. During bedside removal of his PEG tube, the internal bumper was noted to no longer be attached to the tube (Figure 1A). A Foley catheter was placed in the tract to maintain its patency. As the bumper was presumed to be retained in the stomach, esophagogastroduodenoscopy was performed but there was no evidence of foreign body throughout the exam. A computed tomography scan of his abdomen was obtained urgently and showed passage of the bumper into the jejunum (Figure 1B). Serial abdominal radiographs were obtained over the following day showing migration of the bumper into the rectum and was subsequently passed in his stool. Thereafter, the patient has successfully G-J tube placement by interventional radiology. His tube feeds were advanced to goal rate and the patient was no longer having any nausea or vomiting. Discussion: Retained PEG tube internal bumper is a rare complication of PEG tube removal. Prior case reports have described bumper migration into the small bowel where it became lodged and resulted in small bowel obstruction. At least one prior case resulted in small bowel perforation. In cases of bowel obstruction, surgical intervention is warranted. However, in most cases this complication simply warrants clinical monitoring for evidence of obstruction or passage of the PEG bumper; in most reported cases, endoscopic retrieval was not attempted or feasible, and resolved via spontaneous bumper passage through the gastrointestinal tract.Figure 1.: (A) PEG tube with internal bumper no longer attached. (B) CT scan of abdomen showing PEG tube bumper in the jejunum (orange arrow).

S2898 A Unique and Challenging Presentation of Abdominal Pain in Patient of Gastric Bypass Anatomy

Introduction: We are presenting an interesting and challenging case of chronic abdominal pain in a patient of gastric bypass surgery. This patient required Endoscopic ultrasound (EUS) directed transgastric Endoscopy (EDGE) for diagnosis and management of pyloric stenosis in a patient with Roux-en-Y gastric bypass anatomy. Case Description/Methods: 61 years old female presented to emergency department with worsening upper abdominal pain for last 2 years. Patient has history of Roux-en-Y gastric bypass surgery in 2002. Patient had multiple prior evaluations with endoscopies and imaging without any significant etiology identified. She underwent repeat endoscopy with finding of a short gastric pouch and normal-appearing gastrojejunal anastomosis and jejunal limbs. An upper gastrointestinal series and small-bowel follow-through showed normal anatomy. A computed tomography of the abdomen significantly distended bypassed stomach (BS) with fluid. Upon further discussion with Radiology, there was abnormal thickening and elongation of the gastric pylorus noted. Subsequently, an EUS directed transgastric endoscopy was performed revealing significantly dilated BS. An AXIOS stent was placed between gastric pouch and BS in order to decompress as well as gaining access to pyloric channel. Tract was dilated and entered with regular gastroscope. Excessive amount of fluid was aspirated from stomach. A severe friable stenosis found at pylorus. This was only traversed with XP190N gastroscope with outer diameter of 5.4mm. Pathology showed benign inflammation. Repeat EGD was performed through the established tract. Pyloric stricture was then dilated up to 12 mm. Patient was subsequently discharged in stable condition and followed up in clinic. She reported significant improvement in symptoms. Discussion: Despite its overall benefit, there are multiple complications associated with Roux-en-Y gastric bypass. EDGE procedure has been routinely performed in order to gain access to biliary tract. Options to gain access to BS include laparoscopic assisted endoscopy versus surgical exploration. EDGE not only provided therapeutic benefit of decompressing significantly distended excluded stomach but also provided access for examining pyloric channel stenosis/thickening concerning for inflammation or neoplasm. After confirming benign nature, repeated endoscopy was performed for dilation. To our knowledge, this is among first few cases of minimally invasive management of gastric outlet obstruction in patient with gastric bypass anatomy.

Ten-year outcome of one-anastomosis gastric bypass with a biliopancreatic limb of 150 cm versus Roux-en-Y gastric bypass: a single-institution series of 940 patients.

Long-term outcomes of one-anastomosis gastric bypass (OAGB) need to be compared with those of Roux-en-Y gastric bypass (RYGB). The present study evaluates the long-term outcomes at 10-year follow-up of OAGB with a biliopancreatic limb of 150 cm versus RYGB. Private practice, France. Data of patients who underwent OAGB or RYGB as primary or secondary procedures between 2010 and 2011 at a referral center were collected prospectively and analyzed retrospectively. A total of 940 patients underwent OAGB (n = 405) or RYGB (n = 535). Operative time was significantly shorter in the OAGB group. Postoperative morbidity occurred in 17.2% of patients after RYGB versus 8.1% after OAGB (P ≤ .0001). Patients in the RYGB group had a significantly higher rate of kinking of the jejuno-jejunal anastomosis, stenosis of the gastrojejunal anastomosis, and dysphagia for early ulcers. At long term, no differences were found in the rate of severe malnutrition. Cumulated morbidity was significantly higher after RYGB, with higher incidence of internal hernia, anastomotic ulcer, blind-loop syndrome, and hypoglycemia. Conversion to RYGB and laparoscopic exploration for chronic pain were more frequent after OAGB. Surgery for weight regain was significantly more frequent after RYGB. Patients in the OAGB group had significantly lower weight, body mass index, and greater percentage excess, and total weight losses at 120 months. No significant differences were detected in co-morbidity outcomes. After 10 years, both RYGB and OAGB are effective procedures. However, OAGB is associated with shorter operative times and better results in short- and long-term morbidity and weight loss outcomes.

S2875 The Utility of Endoscopic Ultrasound and Fine Needle Biopsy in Diagnosing Remnant Gastric Cancer After Roux-en-Y Gastric Bypass Procedure

Introduction: Roux-en-Y gastric bypass (RYGB) procedure is commonly performed for severe obesity. These patients are at risk of developing remnant gastric cancer. Double-balloon endoscopy (DBE) is typically used to obtain a biopsy. We present two cases of remnant gastric cancer diagnosed using endoscopic ultrasound (EUS). Case Description/Methods: Case 1 is a 76-year-old female status post RYGB who presented with 40-pound weight loss, anorexia and constipation. Labs showed hemoglobin of 6.1 g/dL. Computed tomography (CT) of the chest, abdomen and pelvis revealed hepatic masses and gastric remnant thickening. CA 19-9 was 200,000 U/ml and CEA was 683 ng/dL. Esophagogastroduodenoscopy (EGD) revealed Roux-en-Y gastrojejunostomy with healthy appearing mucosa and a normal jejunum. Colonoscopy showed internal hemorrhoids. Liver biopsy was inconclusive. Concern for remnant gastric cancer, in light of no obvious primary, prompted transgastric EUS guided fine needle biopsy (FNB) of the remnant pouch which confirmed gastric adenocarcinoma.Case 2 is a 49-year-old female status post RYGB who presented with left flank pain,12-pound weight loss and fevers. Labs showed hemoglobin 9 g/dL. CT of the abdomen showed wall thickening involving the gastric pouch and gastric remnant. CEA was 96.6 ng/dL and CA-125 was 348.7 U/ml. EGD revealed a small gastric pouch, gastrojejunal anastomosis characterized by polypoid appearing lesions which were biopsied and found to be benign, and a normal jejunum. Colonoscopy showed inflammation in the cecum and transverse colon and biopsies revealed adenocarcinoma consistent with metastatic signet ring cell carcinoma. Transjejunal EUS guided FNB of the gastric remnant confirmed signet ring cell adenocarcinoma. (Figure) Discussion: EUS is a valuable tool for tissue acquisition especially because DBE has challenges of high operator dependence and long procedure times. Case reports have described EUS guided placement of lumen-apposing metal stents (LAMS) to create a conduit into the gastric remnant to obtain biopsies. However, LAMS are highly operator dependent and carry complications of stent migration, bleeding, infection and perforation. The EUS guided FNB technique is shown in image 1. There were no complications intra or post operatively. Our cases show that EUS with a trans-gastric or trans-jejunal approach provides a less invasive approach that is more operator-friendly, time saving and yields adequate tissue acquisition.Figure 1.: EUS images. A, Case 1: Transgastric view of thickened gastric remnant. B, Case 1: Fine needle biopsy of gastric remnant wall. C, Case 2: Transjejunal view of thickened gastric remnant. D, Fine needle biopsy of gastric remnant wall.

S2894 A Rare and Unique Case of Both Afferent and Efferent Loop Syndromes in a Patient With a Modified Whipple's Procedure

Introduction: The presence of malignant resectable neoplasms in the pancreas and premalignant periampullary lesions are both common indicators for a pylorus-preserving pancreaticoduodenectomy (Modified Whipple/PPPD).We present the case of a 68-year old female with a history of pancreatic adenocarcinoma status post PPPD who presented for radiation enteritis causing a gastric outlet obstruction and duodenojejunostomy anastomosis site distortion, but she was also found to have both Afferent Loop Syndrome on initial admission and Efferent Loop Syndrome on readmission which is rare. Two separate lumen-apposing metal stents (LAMS) under EUS (Endoscopic Ultrasound) guidance were used for treatment. Case Description/Methods: A 68-year-old female presented to the hospital with nausea, vomiting, abdominal pain, and poor oral intake. She had a past medical history of stage II pancreatic adenocarcinoma for which she was treated with PPPD and chemoradiation with adjuvant FOLFIRINOX. She was found to have radiation enteritis resulting in an afferent loop obstruction which was relieved by insertion of a lumen-apposing metal stent (LAMS)(Figure). Following discharge she presented again for recurrent nausea, vomiting and abdominal pain. A CT of the abdomen and pelvis showed gastric distention without any changes of the recently-placed LAMS. Subsequently the patient underwent an EUS-EGD that revealed edema and anatomical distortion of the duodeno-jejunal anastomosis resulting in gastric outlet obstruction with a patent afferent limb however now there was efferent limb obstruction. An endoscope was unable to pass through the stenosis, so a sphincterotome with EUS guidance was done from the antrum into the efferent jejunum and placement of a 20mm x 10mm cautery-enhanced LAMS (Axios), forming a gastrojejunostomy (Figure 2). Discussion: We present a case of a 68-year-old female diagnosed with a stricture secondary to radiation enteritis which led to an afferent loop obstruction. Management was complex as EUS was utilized to eliminate the obstruction. This case is unique because interestingly, the patient was then readmitted with efferent limb obstruction. A gastrojejunostomy was formed using a second cautery-enhanced LAMS to bypass an obstruction that was too stenosed for passage of an endoscope. As shown by our cause, after PPPDs either obstruction of the afferent or efferent limbs of a gastrojejunal anastomosis is a possible complication but rarely do both obstructions occur making our case a very unique presentation.Figure 1.: Afferent loop obstruction relieved by insertion of a lumen-apposing metal stent (LAMS) Figure 2: Efferent loop obstruction with guidewire

Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis.

Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO. MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed. After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0years) and 2116 GJ patients (40.4% female, age: 66.8years) were included. ES patients experienced a shorter survival time (mean difference -24.77days, 95% Cl -45.11 to -4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001). ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.

A Rare Case of Synchronous Gastric Signet Ring Cell Adenocarcinoma Metastasis at the right colon angle

Although it can affect any part of the gastrointestinal system, signet ring cell carcinoma (SRC) is a common malignant entity of stomach cancers. We discuss the case of a patient who had a prior history of gastric adenocarcinoma with signet ring cells, for which he underwent a partial gastrectomy with a gastro-jejunal anastomosis. Four months after surgery, he presented an acute postoperative blockage. Operative findings and pathology exams concluded the presence of SRC at the right angle of the colon. In patients with obstructive symptoms after surgery for SRC neoplasms of the stomach, the possibility of a second lesion should be considered among the differential diagnoses.

How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction?

Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.

A fully stapled technique for gastrojejunal anastomosis creation in robotic Roux-en-Y gastric bypass.

The purpose of this paper is to showcase a fully stapled approach to creating a gastrojejunostomy during a robot-assisted Roux-en-Y gastric bypass. We utilize two robotic 12-mm ports, two robotic 8-mm ports, and one 8-mm assistant port. The tools used are a fenestrated bipolar forceps, vessel sealer, cadiere grasper, needle driver, and a robotic stapler. After the partial gastrectomy, the roux limb is brought up to the gastric pouch where monopolar scissors are used to create a gastrotomy and enterotomy. The gastrotomy is made just above the staple line of the gastric pouch. The enterotomy is created 2cm distal to the roux limb's staple line. The stapler is inserted into both the gastrotomy and enterotomy to create the common channel. A 2-0 vicryl suture is used to place four interrupted sutures across the remaining enterotomy in full thickness bites. An endoscope or Visigi bougie is advanced across the anastomosis into the roux limb before the final suture. The tails of the most lateral and medial sutures are grasped and lifted towards the abdominal wall. The stapler is advanced over the approximated enterostomy while holding tension with the suture tails. The stapler is fired transversely across the suture line to seal the gastrojejunostomy. The staple line may be oversewn with silk sutures. A leak test is performed prior to completing the reconstruction with the jejunojejunostomy. A fully stapled technique of anastomosis creation may reduce operative time, standardizes the process for reproducibility, and increases consistency across operators and patients.

A Rare Cause of Afferent Loop Syndrome: A Case Report

We report a case of a 25-year-old female, with a history of gastrojejunal anastomosis 6 years ago for pyloric stenosis due to intentional corrosive ingestion, who was admitted for jaundice related to the common bile duct stones diagnosed at MRI. The patient had undergone Endoscopic retrograde cholangiopancreatography (ERCP) and upper endoscopy that allowed the diagnosis of afferent loop syndrome related to pyloric stenosis and duodenal stenosis. The afferent loop syndrome was related to hyper pressure in this afferent loop and was managed surgically by performing a jejuno-duodenal anastomosis.

A Rare Case of Synchronous Gastric Signet Ring Cell Adenocarcinoma Metastasis at the Right Colon Angle

Although it can affect any part of the gastrointestinal system, signet ring cell carcinoma (SRC) is a common malignant entity of stomach cancers. We discuss the case of a patient who had a prior history of gastric adenocarcinoma with signet ring cells, for which he underwent a partial gastrectomy with a gastro-jejunal anastomosis. Four months after surgery, he presented an acute postoperative blockage. Operative findings and pathology exams concluded the presence of SRC at the right angle of the colon. In patients with obstructive symptoms after surgery for SRC neoplasms of the stomach, the possibility of a second lesion should be considered among the differential diagnoses.