Percutaneous contrast examination of the stomach after gastric bypass

Investigation of the excluded stomach after Roux-en-Y gastric bypass: The role of percutaneous endoscopy

Accessing the bypassed portion of the stomach via conventional endoscopy is difficult following Roux-en-Y gastric bypass surgery. However, endoscopic examination of the stomach and small bowel is possible through percutaneous access into the bypassed stomach (BS) with a combined radiologic and endoscopic technique. We present a case of obscure overt gastrointestinal (GI) bleeding where the source of bleeding was thought to be from the BS. After conventional endoscopic methods failed to examine the BS, percutaneous endoscopy (PE) was used as an alternative to surgical exploration.

Percutaneous gastrostomy of the excluded gastric segment after Roux-en-Y gastric bypass surgery

A new technique for percutaneous gastrostomy of a decompressed excluded gastric segment after Roux-en-Y gastric bypass (RYGBP) surgery is described and the results in a single institution are reviewed. Computed tomography guidance was used to place a 21- or 22-gauge needle into the lumen of the stomach and distend it to allow placement of a feeding catheter. Ten women underwent the procedure, and despite only three patients having clear access windows, gastrostomy placement was ultimately successful in all 10 patients. Percutaneous gastrostomy of the decompressed excluded gastric segment after RYGBP surgery can be challenging, but a high rate of success can be achieved.

Use of double-balloon enteroscopy to perform PEG in the excluded stomach after Roux-en-Y gastric bypass

BACKGROUND

Because of postoperative complications, patients who have undergone Roux-en-Y gastric bypass (RYGB) for weight loss may require radiographic investigation of the pancreaticobiliary limb or enteral feeding. Gastrostomy-tube placement into the excluded stomach for these indications is typically performed surgically or via fluoroscopic or US guidance; PEG has not been reported as being performed for this purpose. Successful examination of the excluded stomach after RYGB has been reported when using double-balloon enteroscopy (DBE).

OBJECTIVE

To perform PEG in the excluded stomach by using DBE.

DESIGN

Retrospective review.

SETTING

Single, North American tertiary-care center.

PATIENTS

Individuals with postoperative complications after RYGB that requires radiographic examination of the excluded stomach and the pancreaticobiliary limb, or enteral feeding.

INTERVENTIONS

Performance of PEG within the excluded stomach by using DBE.

MAIN OUTCOME MEASUREMENTS

Ability to perform PEG-procedure-related complications and resultant management changes.

RESULTS

PEG was successfully performed by using DBE in 3 of 4 patients with postoperative complications after RYGB. In 2 of the cases, the results of radiographic studies performed with contrast administration through the gastrostomy tube led to significant operative management changes. In the third case, preoperative enteral nutrition was provided by using a gastrostomy tube. PEG placement was not possible in the fourth case because of the lack of abdominal transillumination. Major complications were not observed.

LIMITATIONS

Small sample size, single-center experience.

CONCLUSIONS

PEG placement in the excluded stomach after RYGB by using DBE was safe, technically feasible, and led to management changes in patients in whom it was performed. This procedure should be added to the growing list of indications for DBE.

Gastric surgery for morbid obesity

Patients with 100 pounds of excess weight (BMI greater than 40) have sufficient risk of complications and impairment of function to warrant an operation. There is no operation that will bring all patients to a normal weight without risk. More complex operations may provide greater weight reduction, at least until compensatory changes occur that permit improved digestion and absorption of food. The more complicated the operation, the greater the risk of undesirable side effects. Vertical banded gastroplasty has evolved over the last 35 years as a simple, safe, and effective way to control excessive weight with a minimum risk. This simple operation will produce a normal weight in about 30% of patients and satisfactory weight control in 80% of patients, without need for revision surgery. Optimum results depend on intraoperative measurement of pouch volume and outlet reinforcement, education of patients in the care of their operation, and continual evaluation of the early and long-term effects of these operations.