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CC BY 4.0 · Endoscopy 2024; 56(S 01): E591-E592
DOI: 10.1055/a-2333-9183
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Endoscopic ultrasound-guided gastroenterostomy to treat obstructive gastric twist after laparoscopic sleeve gastrectomy

Authors

  • Laurent Monino 

    1   Department of Gastroenterology & Hepatology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

  • Yannick Deswysen

    2   Department of Digestive Surgery, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

  • Maximilien Thoma

    2   Department of Digestive Surgery, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

  • Pierre H. Deprez 

    1   Department of Gastroenterology & Hepatology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

  • Tom Moreels 

    1   Department of Gastroenterology & Hepatology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Sleeve gastrectomy is the number one bariatric surgical intervention worldwide to treat morbid obesity. The rate of gastric stenosis after sleeve gastrectomy is around 2 to 4% [1] [2]. A gastric twist represents a functional gastric stenosis. Endoscopic management with pneumatic dilation or stent is proposed as first-line therapy [1] [2] [3]. In case of failure, a surgical conversion to Roux-en-Y gastric bypass (RYGB) is performed. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using an oroenteric catheter is a new approach to treat a benign gastric outlet obstruction (GOO) [4] [5]. We report the case of a patient with a gastric twist after laparoscopic sleeve gastrectomy successfully treated with EUS-GE after failure of repeat endoscopic dilatation.

A 69-year old woman underwent sleeve gastrectomy. One month later, she presented symptoms of GOO with a gastric outlet obstruction scoring system (GOOSS) score of 1. Endoscopy showed peptic esophagitis associated with a mid-gastric twist ([Fig. 1] a, b) confirmed by computed tomography scan ([Fig. 1] c). Three sessions of endoscopic dilatation were performed without clinical improvement. An EUS-GE was proposed to “bypass” the mid-gastric twist ([Video 1]). An oroenteric catheter was placed over a guidewire to fill the jejunal lumen. Next, the target jejunal limb was identified by EUS and punctured with the electrocautery-enhanced lumen-apposing metal stent (LAMS) in pure cut mode. The LAMS was deployed connecting the gastric and jejunal lumen without adverse events. Clinical improvement with a GOOSS score of 3 was reported and confirmed by radiology and endoscopy at 1 and 3 months ([Fig. 2] a, b).

Zoom
Fig. 1 Diagnosis of the gastric twist after sleeve gastrectomy. a Twist of the stapling line. b Esophageal dilation and distal gastric obstruction confirmed with endoscopic contrast injection. c Gastric outlet obstruction due to the gastric twist.
Endoscopic ultrasound-guided gastroenterostomy using wireless endoscopic simplified technique with oroenteric drain to treat gastric outlet obstruction due to gastric twist after sleeve gastrectomy.Video 1

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Fig. 2 Endoscopic and radiological imaging 3 months after endoscopic ultrasound-guided gastroenterostomy. a Contrast injection bypassing the gastric twist. b End-to-side gastroenterostomy with lumen-apposing metal stent.

The management of a gastric twist with clinical implications after sleeve gastrectomy is challenging. The improved technical and clinical success of EUS-GE has allowed it to be used in case of a benign GOO due to gastric twist. Moreover, EUS-GE avoided surgical conversion to RYGB. Future studies are needed to define what to do with the LAMS in case of benign gastric outlet obstruction: remove it, replace it, or leave it.

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Conflict of Interest

LM is consultant for Prion Medical and Braun Medical and received speaker’s fees from Olympus Belgium and Olympus Europe. PHD is consultant for Boston Scientific TGM received speaker’s fees from Olympus Belgium and Olympus Europe. Others authors declare that they have no conflict of interest.


Correspondence

Laurent Monino, MD
Department of Hepatogastroenterology, Université catholique de Louvain, Cliniques universitaires Saint-Luc
Avenue Hippocrate 10
1200 Brussels
Belgium   

Publication History

Article published online:
08 July 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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Zoom
Fig. 1 Diagnosis of the gastric twist after sleeve gastrectomy. a Twist of the stapling line. b Esophageal dilation and distal gastric obstruction confirmed with endoscopic contrast injection. c Gastric outlet obstruction due to the gastric twist.
Zoom
Fig. 2 Endoscopic and radiological imaging 3 months after endoscopic ultrasound-guided gastroenterostomy. a Contrast injection bypassing the gastric twist. b End-to-side gastroenterostomy with lumen-apposing metal stent.