Reply to Kobiela et al.

We appreciate the opportunity to respond to the concerns raised by Kobiela et al. in their letter to the Editor.

We agree that surgical gastrostomy is the current gold standard method for providing access to the bypassed stomach in patients with Roux-en-Y gastric bypass (RYGB) anatomy. However, although laparoscopy or open surgery is almost always successful in creating a gastrostomy, minimally invasive endoscopic techniques have certain advantages and, hence, have an important role in the management of these complex patients. At our institution, all such patients are therefore co-managed by the minimally invasive surgery and the pancreaticobiliary services, and any decisions regarding access to the gastric remnant are tailored according to the overall suitability of patients for a given approach.

Endoscopic ultrasound (EUS)-guided access to the remnant stomach, followed by creation of a secure gastrostomy, provides a viable option in patients who may not be suitable candidates for surgery. We described the first case of EUS-guided access for gastrostomy creation in 2010, and recently have seen case reports of our technique described under different names with minimal modifications.

Our technique was born out of necessity when a patient with a history of multiple previous surgeries, dense intra-abdominal adhesions, and a surgical mesh required G-tube placement into the bypassed stomach. EUS enabled us to identify the bypassed stomach, access it using a fine-needle aspiration needle, and place a percutaneous gastrostomy tube [1] [2], thus avoiding complex placement of a surgical gastrostomy tube. We developed this technique further by combining it with sutured gastropexy, followed by trocar placement for endoscopic retrograde cholangiopancreatography (ERCP). This approach has the advantage of allowing ERCP to be performed without delay in patients who cannot wait for 3 – 4 weeks to allow for the gastrostomy to mature, as well as the potential advantage of overall cost reduction.

EUS-guided sutured gastropexy for transgastric ERCP (ESTER) is a single-stage procedure, which requires limited resources, has a short procedure time, and provides safe gastrostomy closure – all the advantages listed for surgical gastrostomy by Kobiela et al. ESTER also preserves RYGB anatomy and, unlike some of the recently described techniques, does not predispose the patient to formation of gastro-gastric fistula.

Sutured gastropexy involves placement of full-thickness, transmural sutures in four quadrants, resulting in a secure gastrostomy with firm adherence of the gastric wall to the anterior abdominal wall, which is similar to the gastrostomy created by surgical means. This reduces the risk of leakage from the gastrostomy site and minimizes the risk of separation of the stomach from the anterior abdominal wall during ERCP. In our recent series, there were no cases of intra-abdominal spillage, dehiscence of gastrostomy or infection at the gastrostomy site [3].

In addition, although not formally studied, patients who underwent ESTER appeared to have less postoperative pain, which may be partly attributable to the fact that maximal insufflation of the gastric remnant allows placement of a gastrostomy at an appropriate anatomical spot without obvious inadvertent traction of the stomach, which may occur when using a surgical approach because the stomach is not distended.

We realize that ESTER has limitations, for example in patients with an antegastric roux limb. However, in our opinion, ESTER is a viable option in appropriately selected patients after careful evaluation of cross-sectional imaging.

• References

• 1 Rueth N, Ikramuddin S, Andrade R. Endoscopic gastrostomy after bariatric surgery: a unique approach. Obes Surg 2010; 20: 509-511
• 2 Attam R, Leslie D, Freeman M et al. EUS-assisted, fluoroscopically guided gastrostomy tube placement in patients with Roux-en-Y gastric bypass: a novel technique for access to the gastric remnant. Gastrointest Endosc 2011; 74: 677-682
• 3 Attam R, Leslie D, Arain MA et al. EUS-guided sutured gastropexy for transgastric ERCP (ESTER) in patients with Roux-en-Y gastric bypass: a novel, single-session, minimally invasive approach. Endoscopy 2015; [Epub ahead of print]. DOI: 10.1055/s-0034-1391124.