Endoscopic exploration of the excluded gastroduodenal segment in patients with Roux-en-Y gastric bypass: indications and findings

Aims The gastroduodenal segment in patients with Roux-en-Y gastric bypass (RYGB) is excluded from conventional endoscopic access. We studied indications and findings of device-assisted enteroscopy (DAE) procedures in the excluded gastroduodenal segment in RYGB patients.

Methods Retrospective analysis of a 5-year (2020-2024) prospective cohort of RYGB patients who underwent DAE of the excluded gastroduodenal segment.

Results A total of 29 RYGB patients (16 female, age 58±2 years) were referred for endoscopic exploration of the excluded gastroduodenal segment because of overt or occult bleeding (n=16; 55%) or because of abnormal radiological CT-findings (n=13; 45%). All DAE procedures were performed under general anaesthesia with endotracheal intubation and with fluoroscopic guidance. The bleeding group contained significantly more male patients (69%) and the time interval between the RYGB surgery and the bleeding was significantly shorter (7±1 year) as compared to the CT-findings group with only 15% of male patients (p=0.0040) and a longer time interval (14±2 years) between RYGB surgery and CT-findings (p=0.0029). DAE in the bleeding group reached the excluded stomach in 94% of the procedures, whereas in the CT-findings group the excluded stomach was only reached in 62% (p=0.0332), and in the remaining 38% the excluded duodenum was reached. In 38% of the bleeding group endoscopic findings were normal as compared to 23% in the CT-findings group (p=0.4037). Positive findings in the bleeding group were ulcers at the Roux-en-Y anastomosis (13%) or at the gastroduodenal level (27%), duodenal angiodysplasia (13%) and diversion gastritis of the excluded stomach (7%). Hemostasis was successfully performed when indicated using hemostatic clips and argon plasma coagulation. Positive findings in the CT-findings group were ulcers at the gastrojejunal anastomosis (15%), duodenal adenoma with high grade dysplasia (8%), pyloric hypertrophy with prolaps (46%) and one case of poorly differentiated adenocarcinoma of the excluded stomach (8%). Endoscopic polypectomy was performed as well as endoscopic biopsy sampling. A total of 16 patients (55%) underwent biopsies of the excluded stomach in search of Helicobacter pylori, but all samples turned out negative. No DAE-related adverse events occurred.

Conclusions High-impact pathology (bleeding ulcers and neoplastic lesions) may occur in the excluded gastroduodenal segment in RYGB patients. Bleeding occurs more often in male patients at an earlier postoperative time interval as compared to pathological radiological CT-findings occurring more often in a later phase with a female predominance. Although neoplastic lesions were found, the majority of suspected tumoral CT-findings turned out to be a benign prolaps of hypertrophic pyloric mucosa. DAE also enables therapeutic interventions like successful hemostasis, polypectomy and tissue sampling. DAE should be considered as a first-line endoscopic approach to diagnose and treat suspected pathology in the excluded gastroduodenal segment in RYGB patients.

Publication History

Article published online:
27 March 2025