Enteroscopy-Assisted EUS-Guided Trans-gastric Intervention After Roux-en-Y Gastric Bypass Surgery

Endoscopic ultrasound-directed trans-gastric interventions (EDGI) using lumen apposing metal stent (LAMS) have been increasingly utilized in patients with Roux-en-Y gastric bypass surgery. We present a case of a 71-year-old woman with Roux-en-Y anatomy presenting with choledocholithiasis and enlarged retroperitoneal lymph nodes. Given inability to identify the excluded stomach on routine EUS, enteroscopy was performed with retrograde filling of the excluded stomach to allow for its localization on EUS. The patient underwent LAMS placement to create a jejuno-gastric anastomosis. Subsequently, she had an ERCP (via the LAMS) for removal of bile duct stone and an EUS with fine needle aspiration of the para-aortic lymph node (via the LAMS) confirming malignancy. The LAMS was removed after 2 weeks and the defect closed with APC and clips. An upper GI series obtained at 4 weeks did not show any residual leak. Patient continues to follow up with oncology for workup of primary malignancy.