|IMAGES AND VIDEOS
|Ahead of print publication
EUS-directed transgastric endoscopy for upper gastrointestinal bleeding
Katia Picazo-Ferrera1, Eugenia Ytuarte-Orantes2, Mario Arturo Ballesteros-Amozurrutia3, Rodrigo Soto-Solis3
1 ABC Medical Center: Departamento de Endoscopia gastrointestinal Centro Medico ABC, CDMX, Mexico
2 Universidad Anahuac, Naucalpan de Juárez, Mexico
3 Departamento de Endoscopia gastrointestinal Hospital Angeles Pedregal, CDMX, Mexico
|Date of Submission||19-Nov-2021|
|Date of Acceptance||15-Feb-2022|
|Date of Web Publication||20-Jul-2022|
ABC Medical Center: Centro Medico ABC, CDMX
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Picazo-Ferrera K, Ytuarte-Orantes E, Ballesteros-Amozurrutia MA, Soto-Solis R. EUS-directed transgastric endoscopy for upper gastrointestinal bleeding. Endosc Ultrasound [Epub ahead of print] [cited 2022 Aug 13]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=351310
A 64-year-old man who had undergone a Roux-en-Y gastric bypass presented because of massive upper gastrointestinal bleeding. The diagnostic and initial therapeutic approach included an upper-endoscopy and colonoscopy without finding the bleeding source. After blood transfusions and hemodynamic stability was reached, a computed tomography angiography was performed. Finding an active extravasation of contrast in the duodenal bulb. After discussion of options, a EUS-directed transgastric endoscopy was proposed. A linear echoendoscope (GF-UCT180; Olympus America, Center Valley, Pa, USA) was advanced into the gastric pouch. Under US guidance, the excluded stomach was located. Under fluoroscopic and US guidance, the remnant stomach was punctured with a 19-gauge EUS needle. As a safety measure; sterile water, methylene blue, and contrast material were injected. Through endosonographic vision a 15-mm × 10-mm cautery-enhanced, lumen-apposing metal stent (LAMS, Axios; Boston Scientific, Natick, Mass, USA) was inserted [Figure 1] creating a gastrogastric fistula between the pouch and the remnant stomach. A gastroscope (GIF-HQ190, Olympus America) was then inserted, followed by a 12 mm CRE balloon (CRE™ Single-Use WIREGUIDED Balloon Dilator) used for dilatation [Figure 2]. The scope was advanced to the duodenal bulb, finding a Forrest IIa ulcer. Conventional endoscopic treatment was performed with submucosal epinephrine injection and mechanical hemostasis with clips [Figure 3]. The LAMS was left until it was verified that there was no rebleeding risk. Bariatric surgery modifies patient's anatomy and physiology, bleeding duodenal ulcer are usually treated with urgent laparotomy or interventional radiology. EUS-directed transgastric procedures may offer a minimally invasive, effective option, with less resource utilization in modified anatomy patients that require endoscopic access to gastric remnant for therapeutic procedures., To the best of our knowledge, this was the first edge procedure used as a therapeutic measure for bleeding in patients with modified anatomy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]