Introduction
Pancreaticoduodenectomy (Whipple) is a complex surgery associated with postoperative morbidity ranging from 30-60%. Delayed gastric emptying and bile reflux gastropathy are well-known problems in long-term survivors. In particular, refractory bile acid reflux following Whipple is challenging to manage. Surgical interventions like Roux-en-Y reconstruction, Billroth II, and Braun entero-enterostomy have been shown to overcome bile reflux for those who have already failed medical and lifestyle modification. We present a case demonstrating the successful management of refractory bile acid reflux in a patient post-Whipple with endoscopic ultrasound (EUS) guided Braun entero-enterostomy.

Case
A 63-year-old female with a history of chronic pancreatitis and pancreatic head mass of unclear etiology status post robotic-assisted Whipple procedure three years prior presented with persistent nausea and bilious emesis since the surgery. An upper endoscopy showed LA grade B reflux esophagitis and diffuse bile acid gastropathy with a large amount of bile pooled in the stomach. Her symptoms were refractory to lifestyle modifications and multiple medications, including antacids, maximal dose of proton pump inhibitors, cholestyramine, and antiemetics, all of which were unsuccessful in controlling her symptoms. After a multidisciplinary discussion, a decision was made to pursue an EUS-guided entero-enterostomy as an alternative to a surgical Braun entero-enterostomy because of the patient's reluctance to undergo another surgery. At one year's follow-up after the procedure, anastomosis remained patent, and symptoms were entirely resolved.

Method
A Whipple anatomy with gastro-jejunal anastomosis was visualized on endoscopy. A mixture of contrast and sterile water was flushed into the small bowel to identify and enlarge the efferent limb. An EUS scope was then introduced into the PB limb, and, using EUS and fluoroscopic visualization, a loop of distended small bowel was identified in the efferent limb. Once an adequate position was found, a 20 mm x 10 mm lumen apposing metal stent (LAMS) was placed from the PB limb into the efferent limb, creating an anastomosis.

Discussion
Our case highlights the use of an EUS-guided entero-enterostomy as a minimally invasive endoscopic alternative to Braun entero-enterostomy to manage severe, intractable bile reflux after Whipple surgery. Surgical interventions are effective in improving refractory bile acid reflux; however, they have an inherent risk of complications in up to 30% of cases and non-negligible morbidity and mortality rates associated with an irreversible intervention. Endoscopic Braun entero-enterostomy is a promising alternative to surgical procedures, especially in patients who are poor candidates or refuse surgery. Future studies are needed to assess the long-term efficacy and safety of this intervention.

Moiz Ahmed

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