Post written by Yervant Ichkhanian, MD, from Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, and Internal Medicine, Henry Ford Hospital, Detroit, Michigan, USA.

This was a case of a 64-year-old woman with a history of Roux-en-Y gastric bypass and a subsequent Whipple reconstruction with pancreatico-gastrostomy (PG) who presented to our center with a clinical picture of a PG anastomotic stricture resulting in pancreatic exocrine insufficiency and abdominal pain.

EUS-guided gastrojejunostomy was created with a lumen-apposing metal stent to facilitate access to the excluded stomach and to perform EUS-guided rendezvous drainage of the pancreatic duct after failed attempts to cannulate the PG in a retrograde fashion. Postprocedure, no adverse events were reported, and the patient symptomatically improved.

Pancreatobiliary interventions among patients with surgically altered anatomy are challenging. We wanted to report a complex pancreatobiliary intervention that was successfully performed after the creation of de novo gastrojejunostomy that served as a conduit to advance an echoendoscope to the excluded stomach.

At high-volume centers with expertise in therapeutic interventions, it is important to include the option of endoscopic interventions in the multidisciplinary discussion for management of such complex pancreatobiliary pathologies.

Surgical interventions can often offer a single-session or “one-stop” management approach for patients with postsurgical pancreatic anastomotic strictures. However, in patients who are not surgical candidates or who prefer to undergo a nonsurgical approach, complex pancreatobiliary interventions can be carried out after the endoscopic creation of transluminal anastomoses. Such procedures are technically challenging, and they are recommended to be performed at high-volume centers with expertise in therapeutic endoscopy.  

Studies are needed to better define the algorithmic management approach of pancreatobiliary interventions among patients with surgically altered anatomy.

EUS-guided gastrojejunostomy using a LAMS. A, An illustration showing the patient’s surgically altered anatomy and the site of the de novo created gastrojejunostomy. B, EUS image showing a 19-gauge FNA needle that was used to puncture the remnant stomach. C, A fluoroscopic image indicating an OTSC that was used to close the pouch puncture site after the technical failure in creating the gastro-gastrostomy. D, A fluoroscopic image indicating the de novo created gastrojejunostomy. E, A cross-sectional CT image indicating the de novo created gastrojejunostomy and the dilated pancreatic duct. F, Endoscopic image showing 2 plastic stents were placed into the gastric remnant through the LAMS, ending in the Roux limb. LAMS, Lumen-apposing metal stent; OTSC, over-the-scope clip.

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