Post gastric-bypass percutaneous enteral access to excluded gastric remnant

Roux-en-Y gastric bypass surgery is commonly performed for weight loss. Complications may occur that require percutaneous enteral access to the larger excluded gastric remnant, as conventional gastrostomy placement into the smaller, non-excluded gastric pouch is not preferred.  Gastric remnant gastrostomy is technically challenging due to lack of enteral access for distention. We summarize our experience in gastric remnant gastrostomy over the last 20 years.

Materials and Methods:

18 patients who underwent gastric remnant gastrostomy from 2004-2024 were identified utilizing a prospectively maintained database. Percutaneous access was obtained by inserting a 21-gauge needle into the gastric remnant using various techniques (Table 1), followed by gastric insufflation and gastrostomy placement. A transbiliary technique was also used, in which an intrahepatic bile duct was accessed using a 21-gauge needle, through which a 5-Fr catheter was directed through the biliary system and into the gastric remnant, followed by gastric insufflation and gastrostomy placement. Indications and technical approaches were reviewed. Technical success and complications were assessed.

Results:

9 patients (50%) presented with decompressed gastric remnant and 9 patients (50%) with dilated gastric remnant. Indications included gastric outlet or small bowel obstruction (8, 44%), failure to thrive (6, 33%), postoperative leak (3, 17%), and percutaneous access for endoscopy (1, 6%).     

The technical success rate was 100%. There were 4 short-term (30-day) complications, including 3 tube dislodgements and 1 balloon rupture. In 3 cases, gastrostomy was replaced and in 1 case, obstruction resolved, and the tube was not replaced. Long-term follow-up was available in 16 patients. 10 patients had the gastrostomy tube removed, secondary to meeting per os nutritional requirement or resolution of post-op leakage or obstruction (6 and 4). 4 patients had the gastrostomy tube removed or converted to surgical jejunostomy secondary to intolerance. 2 patients passed away with chronic gastrostomy tube.    

Conclusion:

Roux-en-Y gastric bypass patients may require gastric remnant gastrostomy for various indications. Our institutional experience demonstrates that such procedures are safe, technically feasible, and effective via numerous approaches.