A 72-year-old man with a history of dementia, decompensated heart failure, and Roux-en-Y
gastric bypass (RYGB) for obesity 30 years previously was admitted with obstructive
jaundice. He also had failure to thrive, with poor oral intake and severe protein
calorie malnutrition requiring enteral nutrition via a nasogastric tube.
An endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography
(ERCP) was planned for management of his obstructive jaundice, along with placement
of a percutaneous endoscopic gastrostomy (PEG) for nutritional supplementation. Given
the previous RYGB, placement of a PEG tube in the gastric pouch would not have been
ideal because of its anatomical location and the high risk of aspiration. Furthermore,
given the bypassed small bowel, this would have precluded the optimal absorption of
enteral nutrition. The EUS-guided gastro-gastrostomy created for the ERCP was fortuitous
in providing access to the excluded stomach, enabling placement of the PEG in the
excluded stomach.
Under EUS guidance, an endoscopic gastro-gastrostomy was performed between the gastric
pouch and the excluded stomach using a 20 × 10-mm cautery-enhanced lumen-apposing
metal stent (AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) ([Fig. 1 a]). The AXIOS stent forming the gastro-gastrostomy was then serially dilated from
10 mm to 18 mm using controlled radial expansion balloons (CRE; Boston Scientific)
([Fig. 1 b]). The proximal flange of the stent was anchored using two endoclips (Instinct Endoscopic
Clip; Cook Medical, Winston-Salem, North Carolina, USA) to prevent stent migration
during the procedure ([Fig. 1 c]).
Fig. 1 Endoscopic views showing: a the gastro-gastrostomy created with a lumen-apposing metal stent (LAMS) placed between
the gastric pouch and the excluded stomach; b balloon dilation of the gastro-gastrostomy; c endoclips placed to prevent stent migration during the procedure; d, e the percutaneous endoscopic gastrostomy (PEG) tube bumper being guided through the
LAMS using grasping forceps; f the successfully placed PEG tube within the excluded stomach.
Next, an esophagogastroduodenoscopy (EGD) was performed through the endoscopic gastro-gastrostomy
and a 20-Fr pull-type PEG tube (EndoVive; Boston Scientific) was successfully placed
into the excluded stomach using the standard technique ([Fig. 1 d – f]; [Video 1]). ERCP showed a distal common bile duct stricture with choledocholithiasis, which
was treated with biliary sphincterotomy, stone extraction, and metal biliary stenting.
Video 1 Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography
(ERCP) with percutaneous endoscopic gastrostomy (PEG) placement (EDGE-PEG) for failure
to thrive, with poor oral intake and severe protein calorie malnutrition, in a 72-year-old
man with a history of dementia, decompensated heart failure, and previous Roux-en-Y
gastric bypass.
Typically, the gastro-gastrostomy is closed after completion of the planned interventions,
given concerns for weight regain; however, permanent reversal may be considered in
patients with progressive nutritional decline. In this case, the patient did well
and was able to gain weight; however, he died from unrelated causes 3 months after
the procedure.
Endoscopy_UCTN_Code_TTT_1AO_2AK
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