ENDOSCOPIC ULTRASOUND (EUS)-GUIDED GASTRIC PER-ORAL ENDOSCOPIC MYOTOMY (G-POEM) FOR THE TREATMENT OF BENIGN GASTRIC OUTLET OBSTRUCTION (GOO) IN THE REMNANT STOMACH IN A PATIENT WITH ROUX-EN-Y GASTRIC BYPASS (RYGB)

Background: Benign and malignant gastric outlet obstruction (GOO) at the remnant stomach in patients with Roux-en-Y gastric bypass (RYGB) can potentially be life-threatening. To date, there is a paucity of endoscopic options aimed at partially reversing GOO of the remnant stomach in patients with RYGB anatomy.
Case Presentation: A 55-year-old female with a 20-year history of RYGB for morbid obesity presented with abdominal pain and distension. She was previously found to have a chronically dilated gastric remnant for which she underwent percutaneous endoscopic gastrostomy (PEG) tube placement and percutaneous endoscopy with the inability to transverse the pylorus. CT-scan and MRI of the abdomen revealed no obvious cause of GOO. After a multidisciplinary discussion, and due to the patient’s preference to avoid a laparoscopic gastrojejunostomy to the remnant stomach and previous PEG tube dislodgment, she opted to undergo a three-stage procedure for the treatment of benign GOO in the remnant stomach.
Endoscopic Methods:During stage 1, an endoscopic ultrasound (EUS)-guided gastrogastrostomy using a 20x10 mm cautery-enhanced LAMS was performed thus creating a gastric-gastric (G-G) access. Esophagogastroduodenoscopy (EGD) of the remnant stomach revealed non-patency of the antropyloric region. Biopsies of this area were unrevealing. Two weeks after the index procedure (stage 2), a 20x10 mm non-cautery enhanced LAMS was placed across the pylorus to facilitate downstream examination of the duodenum and the pancreas with EUS. This was unremarkable, and we thus believed her current GOO was a result of long-term vagal denervation post RYGB surgery and thus proceeded to a gastric per-oral endoscopic myotomy (G-POEM). Three weeks later, the patient underwent stage 3 of her procedure which included removal of the previously placed pyloric LAMS and a G-POEM. She had no post-procedural complications. EGD performed one day post-G-POEM, demonstrated free flow of contrast into the duodenum and no leak, therefore the gastro-gastric LAMS was removed. The patient remains symptom-free at 5 months post-procedure.
Clinical Implications: Benign GOO in the remnant stomach is a rare complication in patients with RYGB anatomy. Vagal afferents are reduced after RYGB, and this can have long-term detrimental effects on the emptying of the stomach and the function/tone of the antropyloric region. There is a paucity of data on treatment of GOO at the gastric remnant in RYGB with the majority aiming to be palliative and with few non-invasive options.
Conclusion: (EUS)-guided gastric access for temporary endoscopy (GATE) continues to be relevant for NOTES procedures. G-POEM appears to be safe and technically feasible in patients with benign GOO in the remnant stomach after RYGB. Larger studies are necessary to examine its long-term efficacy and safety in this population with benign GOO.