EUS-guided Anastomosis Complication in a Patient with Roux-en-Y Gastric Bypass: Dehiscence of the Surgical Anastomosis During Endoscopic Mucosal Resection Across EUS-guided Jejunum-gastric Anastomosis with Lumen Apposing Metal Stent.

Introduction: Roux-en-Y gastric bypass (RYGB) is one of the most common surgical procedures for the management of morbid obesity. However, RYGB poses technical difficulties in exploring the gastric remnant and in performing endoscopic biliary interventions due to altered anatomy. Recently, EUS guided gastro-gastric anastomosis to access the excluded stomach has been introduced in order to allow direct trans-gastric interventions.

Method And Material: We report the case of a 38-year-old female referred to our unit to undergo EUS direct trans-gastric intervention (EDGI) for the management of a small stone in the biliary tract. Pre-procedural CT scan highlighted an abnormal distension of the gastric remnant. EUS guided jejuno-gastric anastomosis was carried out with the deployment of a 15 x 10 mm lumen apposing metal stent (LAMS).

Results: After 3 days, an upper GI endoscopy was performed, highlighting a mobile 25 mm polyp near the pylorus. Therefore endoscopic resection was planned before the performance of the ERCP. Piecemeal endoscopic mucosectomy was carried out with no evidence of any adverse event. However, endoscopic evaluation after specimen retrieval detected an almost complete dehiscence of the anastomosis. Emergency surgery was decided with restoration of the continuity of the gastric cavity to allow future endoscopic examinations/procedures.

Discussion: Here, we report the first case of dehiscence of the surgical gastro-jejunal anastomosis during EDGI procedure. Performing an ERCP during EDGI is probably safer than performing gastric interventions. When performing EDGI, it is paramount to carefully evaluate the type of planned gastric procedure and to adopt a tailored approach according the several variables involved.