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RECURRENT GASTROJEJUNAL ANASTOMOSIS (GJA) STENOSIS AFTER TRANSORAL OUTLET REDUCTION (TORE) IN AN EHLERS-DANLOS SYNDROME (EDS) PATIENT
Renan Prado
*, Arjun Chatterjee, Zurabi Zaalishvili, Michael Cymbal, Leandro Sierra, Stephen A. Firkins, Roma Patel, Akash T. Khurana, Roberto Simons-Linares
Gastroenterology, Cleveland Clinic, Cleveland, OH
Case report:A 53-year-old woman with obesity class III s/p Roux-en-Y gastric bypass (RYGB) in 2006, Ehlers-Danlos Syndrome (EDS), multiple sclerosis, and hypothyroidism, presented with weight re-gain after RYGB. Her pre-bypass weight was 305 lbs (BMI 50.8 kg/m2). The post-bypass nadir weight was 180 lbs (BMI 30.0 kg/m 2) over 1 year. At over 18 years she regained weight and weights 275 lbs (BMI 45.8 kg/m2). She tried multiple lifestyle modifications interventions and presented to our bariatric metabolic clinic for assessment. All options to treat obesity were discussed, and decided to undergo TORe procedure.
She underwent the procedure, and a successful TORe was performed, reducing her GJA from 35 mm. The patient tolerated the procedure without complications and was discharged home on a liquid diet per TORe protocol.
One month after the procedure, she returned with recurrent nausea and vomiting. An esophagogastroduodenoscopy (EGD) was performed and revealed stenosis at the GJA anastomosis, (1 mm D x <1cm L), a through-the-scope (TTS) dilation was performed to 7 mm using a TTS balloon. Although immediate relief following the EGD, her nausea and vomiting recurred 1 week later. She underwent two additional EGD procedures, both of which confirmed severe recalcitrant GJA stenosis, managed with TTS dilation. Due to recurrent stenosis not responding to dilation, placement of a 15 x 10 mm cold lumen opposing metal stent (LAMS, AXIOS stent, Boston Scientific), hemostatic gel (Purastat 3D matrix) applied, and steroids injected at the GJA. Following the stent placement, her nausea and vomiting resolved. Two months after apposition, the LAMS was removed, without evidence of new GJA stenosis.
Discussion:
RYGB is effective for obesity but can lead to weight regain and complications like dumping syndrome. TORe procedure may help address these issues. While TORe is considered safe and complications such as pain and perforation are rare, GJA stenosis is nonetheless a recognized potential issue following the procedure.
A recent meta-analysis with 13 studies showed a 0.35% prevalence of GJA stenosis. The American Society for Gastrointestinal Endoscopy (ASGE) recommends endoscopic balloon dilation for GJA stenosis, though in this case, three attempts were unsuccessful, making necessary the apposition of a LAMS.
Although anastomotic dehiscence is a commonly reported complication in EDS patients following surgery, there are few studies on bariatric procedures in this population, with rare complications documented. Given the known healing challenges in EDS, our patient was at an elevated risk for complications, which may have contributed to the GJA stenosis after TORe and its resistance to balloon dilation.
This unique case highlights the challenge of treating stenosis in an EDS patient.
Figure 1. A. 35 mm dilated GJA before procedure
B. The margin of the anastomosis was treated with Argon Plasma Coagulation (APC).
C. The suturing device was used to place 9 stitches into the tissue surrounding the anastomosis. The suture was then tightened and secured over a 6 mm bougie.
D. GJA stenosis (2 months after TORe procedure)
E. GJA stenosis treated with balloon dilation (1st of 3 attempt)
F. GJA stenosis after 1st dilation
Figure 2. A. GJA stenosis treated with balloon dilation
B. GJA stenosis after 3rd balloon dilation.
C. GJA stenosis just before LAMS placement.
D. Dilation for stent placement.
E. LAMS placed (after 3 sections of balloon dilation)
F. GJA after LAMS removed (2 months after placement).
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