ENDOSCOPIC ULTRASOUND (EUS)-GUIDED GASTROGASTROSTOMY AND TRANSORAL OUTLET OCCLUSION (TORO) FOR ENDOSCOPIC REVERSION OF A ROUX-EN-Y GASTRIC BYPASS (RYGB) FOR MALNUTRITION AND FAILURE TO THRIVE

Background: Malnutrition is a complication of Roux-en-Y gastric bypass (RYGB) and can range from micronutrient deficiencies to protein-calorie malnutrition. Malignant neoplasms and certain surgical complications can increase this risk. Surgical reversion of RYGB can be associated with increased morbidity and mortality.

Case Presentation: A 59-year-old female with a history of a RYGB for obesity and protein-calorie malnutrition (49 kgs, BMI of 16 kg/m2) was admitted with septic shock secondary to intra-abdominal abscesses due to a dislodged percutaneous endoscopic gastrostomy (PEG) placed for management of failure to thrive. She underwent exploratory laparotomy with G-tube removal, gastric wedge resection, J-tube insertion, and vacuum-assisted closure (VAC). Her course was complicated by the inadvertent removal of her J-tube. Given non-surgical candidacy for surgical reversion and previous complications, the patient opted to undergo an endoscopic reversal of her RYGB.

Endoscopic Methods: During stage 1 of her procedure, an endoscopic ultrasound (EUS)-guided gastrogastrostomy using a 20x10 mm cautery-enhanced LAMS was performed thus creating a gastric-gastric (G-G) access. The LAMS was dilated up to 18 mm. Visual confirmation of the remnant stomach was obtained. Two weeks after the index procedure, no gross lesions were noted in the remnant stomach and excellent apposition of the LAMS was noted. Thus, we decided to complete the endoscopic reversion of her RGYB by using a transoral outlet occlusion (TORO) technique. First, a 1.5-2 cm circumferential area of mucosal tissue at the gastrojejunal anastomosis (GJA) rim was ablated using straight fire argon plasma coagulation (APC; forced APC, flow of 0.8 L/min, power of 70 W). Afterward, we loaded an endoscopic suturing system in a dual-channel scope and a single 2.0 nonabsorbable polypropylene suture was then used to place multiple full-thickness stitches around the GJA in a running fashion. The suture was then cinched and complete closure of the GJA was achieved. She had no post-procedural complications and was discharged on BID open-capsule PPI, QID liquid sucralfate, and an antiemetic regimen. At a 2-week post-procedure follow-up, the patient continues to do well with an excellent appetite and weight regain of 3.5 kgs.

Clinical Implications: There is a paucity of data on endoscopic reversion of RYGB aiming at a partial reversion of the RYGB with no targeted therapy for the GJA which can help prevent the bypass of the oral intake of these patients and thus potentially improve nutritional parameters.

Conclusion: Combined EUS-guided gastrogastrostomy and the TORO technique for the endoscopic reversion of a Roux-en-Y gastric bypass (RYGB) appears to be technically feasible in patients with failure to thrive after RYGB. Larger studies are necessary to examine long-term efficacy and safety in this population.