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Video case report

Endoscopic neogastrogastrostomy in a postgastric bypass patient byapplication of an endoscopic antegrade–retrograde

rendezvous technique

Shahzad Iqbal, M.D.a,*, Marc Bessler, M.D.b, Peter D. Stevens, M.D.c, Amrita Sethi, M.D.c

aDepartment of Medicine, Division of Gastroenterology, Winthrop University Hospital, Mineola, New YorkbDepartment of Surgery, Columbia University, Medical Center, New York, New York

cDepartment of Medicine, Division of Gastroenterology, Columbia University, Medical Center, New York, New York

Received March 26, 2012; accepted March 28, 2012

Surgery for Obesity and Related Diseases 8 (2012) 651–653

Keywords: Benign upper gastrointestinal stricture; Gastric bypass; Endoscopic gastrogastrostomy

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The patient, a 45-year-old woman, initially underwentoux-en-Y gastric bypass for morbid obesity. Threeears later, it was complicated by a gastrojejunostomylcer with perforation requiring local repair. Additionalomplications with ischemic bowel and subsequent sur-ical revisions resulted in complete gastric outlet ob-truction. A venting gastrostomy tube was placed in theastric pouch, and a feeding gastrostomy tube was sur-ically placed in the gastric remnant. After some time,he patient strongly expressed her desire to eat orally.ecause of the previous surgical complications and scar

issue, the surgical team requested an endoscopic attempto reconnect the gastric pouch and excluded gastric rem-ant.

An 8.9-mm-diameter endoscope was passed antegradey way of the oral cavity into the gastric pouch. Completebstruction was confirmed by wire probing and contrastnjection. The excluded stomach was then explored by re-oving the 30F feeding gastrostomy tube and inserting a

.9-mm-diameter endoscope. Fluoroscopy was used to con-rm alignment of both endoscopes. Transmural illuminationrom the retrograde endoscope was also used to determinehe best site for access. A 19-gauge endoscopic ultrasoundEUS) needle was passed through the gastric pouch into the

*Correspondence: Shahzad Iqbal, M.D., Department of Medicine, Di-vision of Gastroenterology, Winthrop University Hospital, 222 StationPlaza North, Suite 429, Mineola, NY 11501.

E-mail: siqbal50@gmail.com

1550-7289/12/$ – see front matter © 2012 American Society for Metabolic andhttp://dx.doi.org/10.1016/j.soard.2012.03.010

gastric remnant, followed by a guidewire and 6-mm balloondilation. A 10-mm by 60-mm covered biliary metal stentwas placed. A Gastrografin upper gastrointestinal serieslater showed no leakage (Fig. 1). The patient was started ona liquid diet.

Two weeks later, the stent was removed, followed by12-mm balloon dilation and placement of an 18-mm by15-cm covered esophageal stent. The patient was advancedto a regular diet. Six weeks later, the stent was removed,followed by 20-mm balloon dilation (Fig. 2). The patientresumed a regular diet and remained symptom free at 36months of follow-up (Video).

Discussion

Gastrojejunal anastomotic strictures have been suc-cessfully treated with through-the-scope balloon dilation[1]. However, complete gastrointestinal strictures havetraditionally been managed by surgery. An alternativemethod is the “endoscopic antegrade–retrograde rendez-vous” technique, first described in 1998 by Van Twisk etal. [2] for pharyngoesophageal obstruction. It was laterpplied in 2004 by Davies et al. [3] for colonic strictures.he initial puncture was made by a guidewire [4], needlenife [5], biliary catheter, blunt dissection [6], or EUS

needle (for strictures �3 cm long) [5,7]. The puncturewas performed under endoscopic, fluoroscopic, and/or

EUS guidance, followed by tract dilation with Savary

Bariatric Surgery. All rights reserved.

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652 S. Iqbal et al. / Surgery for Obesity and Related Diseases 8 (2012) 651–653

[4,6] or balloon dilators [5,7]. Self-expandable metallicstents were used in select cases [8,9].

We applied this antegrade–retrograde rendezvousechnique for complete gastric outlet obstruction tochieve gastrogastrostomy. The initial puncture wasade with 19-gauge EUS needle, guided by transillumi-

ation, because the stenosis was �3 cm long. The direc-tion of the puncture was antegrade to avoid any damageto the mediastinal structures. Serial balloon dilations andstenting were performed to allow for tract maturation. No

Fig. 1. Fluoroscopic view. (A) Fluoroscopic confirmation of alignment of bseries showing no leakage at transgastric stenting.

Fig. 2. Endoscopic view. (A) Gastric pouch with initial transgastric stent pla

of lining of newly created gastrogastrostomy tract (arrow) seen after removal of

complication was noted. A similar case was recentlyreported by Wagh and Forsmark [10].

Conclusion

The endoscopic rendezvous technique is a feasible andsafe method for treating complete gastric outlet obstructionby re-establishing the native gastroenteric route after Roux-en-Y gastric bypass in patients who are not candidates forsurgical reconstruction.

egrade and retrograde endoscopes. (B) Gastrografin upper gastrointestinal

(arrow). Note, venting gastrostomy tube next to stent. (B) Epithelialization

oth ant

cement

transgastric stent.

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653Endoscopic Gastrogastrostomy After Gastric Bypass / Surgery for Obesity and Related Diseases 8 (2012) 651–653

Disclosures

The authors have no commercial associations that mightbe a conflict of interest in relation to this article.

Appendix

Supplementary data

Supplementary data associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/j.soard.2012.03.010.

References

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[8] Guan YS, Sun L, Li X, Zheng XH. Successful management of abenign anastomotic colonic stricture with self-expanding metallicstents: a case report. World J Gastroenterol 2004;10:3534–6.

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