P1126 - Single-Stage EUS-Guided Gastrogastrostomy Secured With Clips With Anchor Prongs to Treat Massive Gastrointestinal Hemorrhage in Roux-en-Y Gastric Bypass

Award: Presidential Poster Award

Bjorn Rodriguez, MS¹, David Jonason, MD², Daryl Ramai, MD, MPH, Msc³, Jay DuBroff, MD, MPH², Gregory Toy, MD², Judith Staub, MD², Christopher Ko, MD, MA^2
1St. George's University School of Medicine, Salt Lake City, UT; ²University of Utah, Salt Lake City, UT; ³University of Utah Health, Salt Lake City, UT

Introduction: EUS-guided gastrogastrostomy (EUS-GG) or Gastric Access Temporary for Endoscopy (GATE) enables endoscopic access and interventions of the gastric remnant and duodenum in patients with Roux-en-Y gastric bypass (RYGB) by deploying a transgastric lumen-apposing metal stent (LAMS). Its use to treat upper gastrointestinal bleeding (UGIB) has scarcely been reported. We present a case of refractory UGIB in a RYGB patient successfully managed with single-stage GATE after securing with CAPs.

Case Description/Methods: A 68-year-old female with RYGB presented with melena and syncope with NSAID use after knee surgery. Her hemoglobin (Hb) was 10.2, BP 100/94, HR 51. She later became hypotensive with hematochezia and a repeat Hb of 6.6 requiring massive transfusion protocol (MTP) and ICU transfer. CT angiography found hyperdense fluid in the gastric remnant. Interventional radiology (IR) angiography showed possible left gastric artery extravasation which was embolized. Massive hemorrhage persisted requiring two more rounds of MTP. Endoscopy excluded bleeding proximal to the jejunojejunostomy. Tagged RBC scan reconfirmed bleeding from the gastric remnant. The left gastric artery was re-embolized as was the right gastroepiploic. However, transfusion-dependent hemorrhage persisted. Having exhausted all conventional interventions, GATE was pursued.

 

The gastric remnant was identified on EUS, dilute contrast was injected with a 19-gauge needle for wall approximation and EUS-GG was created with a 20 x 10 mm LAMS using electrocautery. The LAMS was balloon dilated to 18 mm and secured with two CAPs (Mantis Clips, Bos Sci) to the gastric pouch (Fig. 1a). The stent was traversed and a 3 cm ulcer with a spurting vessel was found in the duodenal bulb (Fig. 1b,c). Hemostasis was achieved with clips, epinephrine and bipolar cautery (Fig. 1d). IR then embolized the gastroduodenal artery to reinforce hemostasis using our clips for localization. She was weaned off pressors and had an unremarkable recovery without rebleeding.

Discussion: EUS-GG interventions are usually done in two stages to allow tract maturation to minimize stent migration/perforation ( >17%). Our practice has piloted using CAPs, designed for defect closures, to secure stents to minimize migration. To our knowledge, this is the first reported use of single-stage gastrogastrostomy anchored using CAPs and a unique case showing its utility to safely treat a difficult massive UGIB. This practice expands the efficacy and safety of endoscopic interventions.



Disclosures:


Bjorn Rodriguez, MS¹, David Jonason, MD², Daryl Ramai, MD, MPH, Msc³, Jay DuBroff, MD, MPH², Gregory Toy, MD², Judith Staub, MD², Christopher Ko, MD, MA². P1126 - Single-Stage EUS-Guided Gastrogastrostomy Secured With Clips With Anchor Prongs to Treat Massive Gastrointestinal Hemorrhage in Roux-en-Y Gastric Bypass, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.