Background: Gastric access temporary for endoscopy (GATE) via endoscopic ultrasound (EUS)-guided stent placement between the gastric pouch or jejunum and excluded stomach is increasingly used in Roux-en-Y gastric bypass (RYGB) for evaluation of the remnant stomach or to facilitate endoscopic retrograde cholangiopancreatography (EDGE). While GATE has high technical success, stent placement to facilitate access is not always feasible. We aimed to identify radiographic, fluoroscopic, and endosonographic predictors of failure in patients undergoing GATE.
Methods: Consecutive patients undergoing GATE were matched 3:1 on procedure success. All procedures were performed at a single high-volume center. Decision to attempt or abort stent placement was at the discretion of the advanced endoscopist (AE) and confirmed by a second AE. Radiographic images were reviewed by an attending radiologist blinded to procedure success. Features indicating quality of the gastric window and potential difficulties with access were collected including length, relationship (anterior, posterior, right or left lateral), and orientation (straight/curved) of the gastric pouch, blind limb, and excluded stomach, the presence of poor contact due to thickened tissue, calcification, or surgical material, and intervening vasculature. Fluoroscopic and endosonographic data were also collected. Primary outcome was radiographic criteria associated with GATE failure. Secondary outcomes were endosonographic and fluoroscopic predictors of GATE failure. Proportions were compared using Fisher’s exact test and continuous variables using student’s t-test. A p-value of 0.05 was considered significant.
Results: 40 patients (30 successful, 10 aborted, 82.5% F) who underwent GATE attempts over a 24-month period were included. Mean (±SD) age and time since RYGB were 62.8±11.9 and 15.1±8.6 years, respectively. There were no differences in demographics between groups (Table 1). Cumulative number of radiographic risk factors including intervening vasculature and indicators of poor contact between the gastric pouch/blind limb and excluded stomach was associated with GATE failure (OR 26.1 [95% confidence interval 0.004, 0.337]; p=0.004) (Figure 1). Two or more factors increased likelihood of failed GATE (p<0.05). There were no significant differences between length, relationship, or orientation of gastric pouch, blind limb, or excluded stomach between groups. Echoendoscope angulation or tip deflection, intervening vasculature, distance to excluded stomach, rapid emptying and/or insufficient filling of contrast were predictors of GATE failure.
Conclusion: Radiographic findings of intervening vasculature or insufficient contact between gastric pouch/blind limb and excluded stomach seem to predict GATE failure. Alternate approaches should be considered in early management. Prospective studies are underway.

Kevin Platt

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