EUS-assisted, fluoroscopically guided gastrostomy tube placement in patients with Roux-en-Y gastric bypass: A novel technique for access to the gastric remnant

Background: Access to the excluded gastric remnant in patients after Roux-en-Y gastric bypass for gastrostomy tube placement or therapeutic endoscopy is a technical challenge. Available techniques include interventional radiologyplaced gastrostomy, deep enteroscopy, and surgical gastrostomy; however, these techniques are hampered by complications, technical complexity, or invasiveness. Objective: To describe a novel technique that uses EUS to insufflate the excluded gastric remnant for fluoroscopically guided percutaneous gastrostomy placement. Design: Retrospective study. Setting: University hospital. Patients: Ten patients who required gastrostomy placement after Roux-en-Y gastric bypass. Interventions: EUS was used to puncture the excluded stomach through the gastric pouch or jejunum. The stomach was insufflated, and a direct percutaneous gastrostomy placed under fluoroscopic guidance in the distended stomach. Main Outcome Measurements: Feasibility, safety, and efficacy of EUS-assisted, fluoroscopically guided gastrostomy tube placement. Results: Technical success of EUS-assisted gastrostomy was achieved in 9 of 10 patients(90%). There were no complications. Limitations: Single-institution study, small sample size. Conclusions: EUS-assisted, fluoroscopically guided gastrostomy tube placement may be a safe and feasible technique to obtain enteral access to the excluded gastric remnant in patients after Roux-en-Y gastric bypass at specialized centers.