Post written by Shailendra Singh, MD, and Ethan M. Cohen, MD, from the Department of Gastroenterology & Hepatology, West Virginia University, Morgantown, West Virginia, USA.

We present a case of a 63-year-old woman who underwent a pancreaticoduodenectomy (Whipple procedure) for a rapidly expanding pancreatic head mass. Three years after the surgery, she developed severe persistent nausea and bilious emesis because of bile reflux. Her symptoms were refractory to conservative measures, including lifestyle modifications and medications such as antacids, maximum-dose proton pump inhibitors, cholestyramine, and antiemetics.

Endoscopic evaluation revealed a sliding hiatal hernia with Los Angeles grade B reflux esophagitis and diffuse bile acid gastropathy characterized by a large amount of bile in the stomach. Given the severity of her symptoms and the findings on endoscopy, a multidisciplinary team—including surgical services and interventional gastroenterology—discussed management options. The patient ultimately opted for an EUS-guided enteroenterostomy as an alternative to surgical intervention.

The procedure, demonstrated in the accompanying video, involved placement of a self-expandable lumen-apposing metal stent (LAMS) between the pancreatico-biliary and efferent limbs under EUS guidance. The LAMS was left in situ for 6 months before successful removal endoscopically. The patient’s postoperative recovery was uneventful, and she remains asymptomatic with a persistently patent fistula more than 18 months after the procedure.

Surgical interventions are commonly pursued for managing intractable bile acid reflux, particularly after a Whipple procedure. However, these surgeries carry significant risks, including prolonged structural adverse events in up to 30% of cases, as well as notable morbidity and mortality because of the irreversible nature of the intervention.

In contrast, EUS-guided enteroenterostomy presents a minimally invasive and promising alternative, especially for patients who are poor surgical candidates or who prefer to avoid surgery. In this video, we describe the technique and discuss details of the procedure. By showcasing this video, we aim to highlight the feasibility of this innovative technique, which can offer a safer, minimally invasive approach to managing complex cases of bile acid reflux after major pancreatic surgeries.

In patients with refractory bile acid reflux after a Whipple procedure, it is feasible to perform endoscopic enteroenterostomy by experienced interventional endoscopists. Although no long-term data are available on the dwell time for LAMSs to ensure that the fistula remains patent, in our case, 6 months was sufficient.

Depiction of a post-Whipple surgical anatomy, with green arrows representing the flow of bile acid from the liver (not pictured) (left). The endoscopic view of the opening of the afferent and efferent limbs as seen from the stomach (right). A, Afferent limb; E, efferent limb; S, stomach; star, gastrojejunal anastomosis that defines the separation point between the 2 limbs.

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