Post written by Manol Jovani, MD, MPH, from the Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland.
Biliopancreatic diversion (also known as duodenal switch) is a complex bariatric surgery that includes a sleeve gastrectomy and long Roux-en-Y intestinal bypass. This is a very effective surgery for weight loss, but it can be complicated by severe malnutrition. In such cases, surgical reversal of the duodenal switch is done by creating a proximal anastomosis between the alimentary and biliopancreatic limbs. However, thanks to the advent of lumen-apposing metal stents (LAMS) the same procedure can be performed endoscopically.
A 43-year old female with history of biliopancreatic diversion for obesity 9 years prior was hospitalized for diarrhea, malnourishment, significant weight loss (42 pounds) and failure to thrive. Numerous evaluations for neoplasia were negative. It was deemed that the patient’s malnourishment and weight loss were due her altered anatomy. Thus, considering her general condition, an endoscopic ultrasound (EUS)-guided duodenal switch reversal was performed. The aim was to recreate the communication between the biliopancreatic and alimentary limbs similar to that created by surgeons, and thus improve nutrients’ digestion and absorption.
The procedure was performed in an endoscopy unit. The echoendoscope was directed under fluoroscopic guidance toward the expected location of the duodenal stump and biliopancreatic limb in the right upper quadrant. The duodenal lumen was identified with EUS, and a 19-gauge FNA needle was used to access it. The location was confirmed with fluoroscopic imaging by contrast injection. About 500 cc of contrast and saline was injected to clearly define the anatomy and distend the biliopancreatic limb by connecting a pump to the FNA needle. We used saline to avoid hyponatremia. Intravenous glucagon was given to slow the peristalsis of the biliopancreatic limb and aid in fluid retention. Once the biliopancreatic limb was clearly defined and distended, a jejunoduodenostomy was created under EUS guidance with the freehand technique using a cautery-assisted LAMS.
The patient tolerated oral feeding well and gained significant weight. About 8 months later, the patient requested removal of the stent because she had gained over 50 pounds. In conclusion, endoscopic reversal of biliopancreatic diversion by means of LAMS is feasible. Long-term outcomes of this procedure should be explored in large studies, and this procedure should be compared with surgical duodenal switch reversal.
Why did you feel it was important to showcase this particular video?
This is an example of the power of advanced endoscopy to dramatically improve clinical conditions of patients with minimally invasive procedures. It is a reminder that advances in endoscopic techniques may offer patients the same outcomes, or even better ones, as surgery.
What can other endoscopists learn from your experience?
This case shows that lumen-apposing metal stents can be successfully used for both creation of new diversions (such as for example EUS-guided gastrojejunostomy) as well as reversal of previously created surgical diversions (as in this case). Thinking outside the box in advanced endoscopy can significantly improve clinical care for our patients.
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