Background

Patients with surgically altered gastrointestinal anatomies are at increased risk of anastomotic strictures and gastric outlet obstruction. Laparoscopic gastrojejunostomy has been the traditional approach for such cases. However, with the advance in endoscopy, endoscopic ultrasound-guided gastrojejunostomy provides a novel efficacious and minimally invasive technique for palliation of gastric outlet obstruction.

Methods

A 56-year-old female patient with a history of open roux en gastric bypass presented with recurrent vomiting in setting of iatrogenic gastric outlet obstruction (GOO) at pylorus level and gastro-gastric fistula representing dominant exit of gastric pouch. She underwent an EUS guided gastroduodenal anastomosis creation for palliation of GOO. One day post procedure, she presented with peritonitis due to leakage at anastomosis site. Urgent laparatomy was performed, but site of leak could not be identified. Hence, she underwent another endoscopy with good control of leak. Repeat CT abdomen/pelvis showed better control of leak with residual intra-abdominal collections. Hence, a third endoscopy was performed to upgrade the stents for additional sealing at anastomosis site. Patient had a course of improvement with follow up CT abdomen/pelvis scan showing no residual leak and good approximation of excluded stomach and small bowel. Patient was discharged 2 months later and reported resolving of nausea and vomiting.

Conclusions

In challenging anatomies including post-surgical ones, endoscopic ultrasound-guided gastrojejunostomy can be performed to provide access and successful palliation of gastric outlet obstruction. Nevertheless, complications could arise and approaching them as a multidisciplinary team that includes experts in surgery and endoscopy is important.