Background
Gastrojejunal (GJ) anastomotic strictures are a relatively common complication, occurring in up to 15% of patients after Roux-en-Y gastric bypass (RYGB). Endoscopic balloon dilations are the initial therapeutic procedure for these anastomotic strictures. Lumen-apposing metal stents (LAMS) have been used to treat strictures refractory to balloon dilation. However, some patients may not respond to the placement of LAMS. We present a case series of creation of a fresh anastomosis between the gastric pouch and Roux limb for treatment of refractory anastomotic strictures, which have failed balloon dilations and LAMS placement.

Case 1
Patient is a 69-year-old female with a history of RYGB complicated by severe stenosis of GJ anastomosis. She failed balloon dilations, and a LAMS was placed across the stricture. Her symptoms initially improved, and the stent was removed 3 months later. One month after stent removal, she developed similar symptoms, and EGD showed re-stenosis of her anastomotic site. She underwent the creation of a fresh EUS-guided GJ anastomosis with complete resolution of symptoms at 3 months follow-up.
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Case 2
49-year-old female with a history of RYGB complicated by GJ anastomosis site strictures underwent multiple EGDs with dilation of the GJ anastomosis and placement of LAMS. Patient subsequently underwent EUS-guided creation of a fresh GJ anastomosis between the blind pouch and the roux limb, which resulted in resolution of her symptoms.

Case 3
A 63-year-old female with a history of RYGB complicated by anastomosis site stenosis requiring multiple dilations presented with complaints of dysphagia, vomiting and weight loss. She underwent LAMS placement; however, she had a recurrence of symptoms after the removal of LAMS. She underwent the creation of a fresh GJ anastomosis using a LAMS with resolution of symptoms.

Case 4
Similarly, a 39-year-old female with a history of RYGB complicated GJ anastomosis stricture was treated with balloon dilation and LAMS. Given previous failed endoscopic interventions, she underwent EUS-guided creation of a fresh GJ using a LAMS, which resulted in the resolution of her symptoms.

Discussion
Endoscopic management of gastro-jejunal strictures after RYGB is preferred over surgical revision due to technical difficulty and morbidity of surgical revisions. LAMS placement across the anastomotic stricture can be considered in cases that fail balloon dilation. If a recurrence of stricture is seen even after LAMS placement, endoscopic creation of fresh anastomosis can be considered. In our case series, four patients underwent successful creation of a fresh EUS-guided GJ anastomosis using a LAMS with resolution of their symptoms. This novel intervention unveils a promising new approach for management of refractory anastomotic strictures.

Joseph Simmons

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