Percutaneous radiologic gastrostomy is indicated for patients who require enteral access for nutritional support, medication administration, and/or decompression. Some patients have comorbidities that increase procedural risk and may require deviation from the conventional approach, such as upper gastrointestinal tract obstruction, ascites, and postsurgical anatomy. In such cases, technical modifications and/or changes to the standard approach may be needed. This review describes several specific scenarios that require special consideration, focusing on clinical management options, risk mitigation techniques, and supportive evidence.

Roux-en-Y gastric bypass (RYGB) is a common surgical treatment for morbid obesity, but rare complications involving the excluded gastric remnant can pose significant challenges. A 65-year-old female with a history of RYGB presented with sudden onset of left upper quadrant abdominal pain, bloating, nausea, and loss of appetite. Laboratory tests revealed leukocytosis. An initial CT scan showed significant distention of the excluded stomach, suggesting possible obstruction. While preparing for percutaneous decompression, her abdominal pain worsened acutely. A repeat CT scan demonstrated decompression of the excluded stomach and new free fluid in the abdomen, indicating a perforation. Emergent exploratory laparotomy uncovered a large necrotic perforation in the excluded gastric remnant and extensive adhesions from prior surgeries. A partial gastrectomy and antrectomy were performed to remove the perforated tissue. Pathological examination revealed ulcerated gastric mucosa with acute and chronic inflammation, reactive gastropathy, and no evidence of Helicobacter pylori infection or malignancy. Postoperatively, the patient recovered well with supportive care and was discharged home. Diagnosing complications in the excluded stomach after RYGB is challenging due to altered anatomy and nonspecific symptoms. Maintaining a high index of suspicion is essential when evaluating post-RYGB patients with unexplained abdominal pain. Early recognition and prompt surgical intervention are critical for favorable outcomes in these patients.

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic intervention for pancreaticobiliary duct diseases. Surgically altered anatomy (SAA) makes performing successful ERCP challenging. In this review article the concept of endoscopic ultrasound guided pancreaticobiliary drainage (EUS-PBD) in cases of SAA where conventional ERCP fails or is not possible will be reviewed. EUS-PBD serves as an emerging and promising alternative for pancreaticobiliary therapy in the hands of skilled endoscopists compared to conventional therapies such as device-assisted ERCP, laparoscopic-assisted ERCP, or percutaneous drainage. The purpose of this review is to discuss the rationale, technique and current published outcomes on EUS-PBD for SAA.

The purpose of the study is to evaluate the indications, techniques, and outcomes for percutaneous gastrostomy placement in the gastric remnant following Roux-en-Y gastric bypass (RYGB) in bariatric patients.

Retrospective chart review and summary statistical analysis was performed on all RYGB patients that underwent attempted percutaneous remnant gastrostomy placement at our institution between April 2003 and November 2016.

A total of 38 patients post-RYGB who underwent gastric remnant gastrostomy placement were identified, 32 women and 6 men, in which a total of 41 procedures were attempted. Technical success was achieved in 39 of the 41 cases (95%). Indications for the procedure were delayed gastric remnant emptying/biliopancreatic limb obstruction (n = 8), malnutrition related to RYGB (n = 17), nutritional support for conditions unrelated to RYGB (n = 15), and access for endoscopic retrograde cholangiopancreatography (ERCP, n = 1). Insufflation of the gastric remnant was performed via a clear window (n = 35), transhepatic (n = 5), and transjejunal (n = 1) routes. Five complications were encountered. The four major complications (9.8%) included early tube dislodgement with peritonitis, early tube dislodgement requiring repeat intervention, intractable pain, and upper gastrointestinal bleeding. A single minor complication occurred (2.4%), cellulitis.

Patients with a history of RYGB present a technical challenge for excluded gastric remnant gastrostomy placement. As the RYGB population increases and ages, obtaining and maintaining access to the gastric remnant is likely to become an important part of interventional radiology's role in the management of the bariatric patient.

Laparoscopic Roux-en-Y gastric bypass (RYGB) is widely applied in the treatment of morbid obesity. Health personnel meeting these patients should thus be familiar with the potential clinical consequences of the modified anatomy induced by the surgery. After a RYGB, the stomach is left in situ after the closure of the upper part of the organ. This blind-ended gastric remnant may cause complications and surgical emergencies, but also opportunities for diagnostic and therapeutic intervention. The present review focuses on complications related to the gastric remnant including bleeding and acute dilatation in the early postoperative period and later adverse events such as gastroduodenal peptic disease, tumors, gastrogastric fistulas, and late dilatation. Opportunities offered by the remnant, including minimal invasive or open access for enteral nutrition, and therapeutic and diagnostic access to the bile ducts, the duodenum, and the gastric remnant, which is challenged by the modified anatomy, are discussed. Reversal of the gastric bypass and gastrointestinal reconstruction after esophageal resection have been commented on. The review aims to improve the awareness of issues related to the gastric remnant for physicians involved in the treatment and the follow-up of patients after a RYGB.

Bariatric surgery is the most effective treatment for morbid obesity. Due to the high volume of weight loss procedures worldwide, the general surgeon will undoubtedly encounter bariatric patients in his or her practice. Liberal use of CT scans, upper endoscopy and barium swallow in this patient population is recommended. Some bariatric complications, such as marginal ulceration and dyspepsia, can be effectively treated non-operatively (e.g., proton pump inhibitors, dietary modification). Failure of conservative management is usually an indication for referral to a bariatric surgery specialist for operative re-intervention. More serious complications, such as perforated marginal ulcer, leak, or bowel obstruction, may require immediate surgical intervention. A high index of suspicion must be maintained for these complications despite "negative" radiographic studies, and diagnostic laparoscopy performed when symptoms fail to improve. Laparoscopic-assisted gastric band complications are usually approached with band deflation and referral to a bariatric surgeon. However, if acute slippage that results in gastric strangulation is suspected, the band should be removed immediately. This manuscript provides a high-level overview of all essential bariatric complications that may be encountered by the acute care surgeon.

Several thousands of laparoscopic mini-gastric bypass have been performed globally by a number of surgeons. There is growing evidence that mini-gastric bypass is a safe and effective procedure. We report a rare case of massive gastric remnant dilation in a 45-year-old man after laparoscopic mini-gastric bypass. Acute gastric dilatation is a surgical emergency. In our case, a triad of clinical suspicion, laboratory profile, and emergency radiologic investigation were essential for early diagnosis and management. Image-guided gastrostomy tube placement provides an effective decompression of the gastric remnant. A literature review revealed no previous reports of similar complications in mini-gastric bypass.

Roux-en-Y gastric bypass is a commonly performed bariatric procedure worldwide. Gastric remnant dilatation is an uncommon early complication of this procedure that can be fatal if treatment is delayed, as it can cause peritonitis and death. Herein we report a gastric bypass patient who presented with profound shock 3 months after the surgery. After resuscitation and evaluation, she was diagnosed as having a massive dilatation of gastric remnant, which we managed with percutaneous drainage.

Access to the excluded gastric remnant in patients after Roux-en-Y gastric bypass for gastrostomy tube placement or therapeutic endoscopy is a technical challenge. Available techniques include interventional radiology-placed gastrostomy, deep enteroscopy, and surgical gastrostomy; however, these techniques are hampered by complications, technical complexity, or invasiveness.

To describe a novel technique that uses EUS to insufflate the excluded gastric remnant for fluoroscopically guided percutaneous gastrostomy placement.

Retrospective study.

University hospital.

Ten patients who required gastrostomy placement after Roux-en-Y gastric bypass.

EUS was used to puncture the excluded stomach through the gastric pouch or jejunum. The stomach was insufflated, and a direct percutaneous gastrostomy placed under fluoroscopic guidance in the distended stomach.

Feasibility, safety, and efficacy of EUS-assisted, fluoroscopically guided gastrostomy tube placement.

Technical success of EUS-assisted gastrostomy was achieved in 9 of 10 patients(90%). There were no complications.

Single-institution study, small sample size.

EUS-assisted, fluoroscopically guided gastrostomy tube placement may be a safe and feasible technique to obtain enteral access to the excluded gastric remnant in patients after Roux-en-Y gastric bypass at specialized centers.

To review our experience with early jejunojejunostomy obstruction (JJO) at a large academic teaching hospital and provide a management algorithm. Early JJO is a known and often overlooked complication of laparoscopic Roux-en-Y gastric bypass.

From 2003 to 2007, 1097 patients underwent laparoscopic Roux-en-Y gastric bypass at our institution. Data, including patient demographics, co-morbidities, intraoperative data, peri- and postoperative complications, and outcomes, were prospectively recorded and retrospectively reviewed.

Early post-laparoscopic Roux-en-Y gastric bypass JJO occurred in 13 patients (1.2%). The average time to presentation was 15 days (range 5-27). Patients presented with a combination of nausea, vomiting, and abdominal pain; all underwent computed tomography to confirm the diagnosis. The causes of JJO included dietary noncompliance (46%), anastomotic edema (23%), narrowing of the jejunojejunostomy at surgery (23%), and luminal clot (8%). Management was determined using our proposed treatment algorithm. Three patients (23%) required operative intervention, with the remainder successfully treated conservatively.

From our experience, we propose a treatment algorithm for standardized management of early JJO, reserving reoperation for those who are acutely ill on presentation or those in whom conservative management fails. A review of our series using this algorithm has suggested that most patients can be successfully treated nonoperatively; however, bariatric surgeons must maintain a low threshold for surgical re-intervention in cases in which rapid recovery is not seen.

A patient with a history of a laparoscopic gastric bypass presented with a perforated duodenal ulcer. The ulcer was laparoscopically oversewn, and an omentoplasty was performed. Postoperatively, a broad spectrum antibiotic and a proton pump inhibitor were administrated. Several questions arise regarding the diagnosis and treatment of duodenal ulcers after gastric bypass. What are the diagnostic tools to detect a duodenal ulcer, and how should Helicobacter pylori be diagnosed after gastric bypass? The key question is whether the bypassed stomach should be resected as a definitive treatment for complicated duodenal ulcers.

Biliopancreatic limb obstruction in Roux-en-Y gastric bypass is an infrequent complication that should be recognized early to avoid the risk of peritonitis and death. In this manuscript, we report a case of acute gastric remnant dilatation secondary to intraabdominal hematoma provoked by trocar injury that was compressing the second portion of duodenum lumen. To treat this problem, we decided on a less invasive treatment consisting of percutaneous decompression of the stomach. The procedure was performed using sonographic guidance with local anesthesia, thus, avoiding a new surgical procedure. In this selected case, percutaneous radiological catheter placement provided an effective decompression of the excluded gastric remnant until spontaneous resolution of the obstruction.

A new technique for percutaneous gastrostomy of a decompressed excluded gastric segment after Roux-en-Y gastric bypass (RYGBP) surgery is described and the results in a single institution are reviewed. Computed tomography guidance was used to place a 21- or 22-gauge needle into the lumen of the stomach and distend it to allow placement of a feeding catheter. Ten women underwent the procedure, and despite only three patients having clear access windows, gastrostomy placement was ultimately successful in all 10 patients. Percutaneous gastrostomy of the decompressed excluded gastric segment after RYGBP surgery can be challenging, but a high rate of success can be achieved.

The bypassed portion of the stomach is difficult to access and evaluate after Roux-en-Y gastric bypass. Access to the excluded stomach may be needed for nutritional support or decompression owing to acute distension and obstruction. We report our experience with percutaneous, computed tomography (CT)-guided gastrostomy tube placement into the gastric remnant after laparoscopic Roux-en-Y gastric bypass (LRYGB).

Of 569 consecutive LRYGB procedures performed, 9 patients underwent successful percutaneous, CT-guided gastrostomy placement. One additional patient was referred from another facility. We reviewed the indications, interval from surgery to the intervention, interval to removal, complications, and success or outcome of the procedure in our patient population.

Ten patients underwent percutaneous, CT-guided gastric remnant gastrostomy tube placement. The indications included distended gastric remnant in 6, nutritional access in 4, and remnant drainage after leak in 1. Of the 10 patients, 2 had undergone previous gastric operations. The attempt at percutaneous gastrostomy was unsuccessful in 1 additional patient, who subsequently required laparoscopic gastrostomy (success rate 91%).

In selected patients after LRYGB, CT-guided gastrostomy tube placement is safe and efficient. It may be used to manage complications of LRYGB, serve as a bridge to definitive surgery, or offer a convenient route for enteral nutritional support.

This is a study of the causes of 30-day postoperative death following surgical treatment for obesity and a search for ways to decrease an already low mortality rate.

Data were contributed from 1986-2004 to the International Bariatric Surgery Registry by 85 sites, representing 137 surgeons. A spread-sheet was prepared with rows for causes and columns for patients. The 251 causes contributing to 93 deaths were then marked in cells wherever a patient was noted to have one of the causes. Rows and columns were then moved into positions that provided patterns of best fit.

11 patterns were found. 10 had well known initiating causes of death. Overall operative 30-day mortality was 0.24% (93 / 38,501). The most common cause of death was pulmonary embolism (32%, 30/93). 14 deaths were caused by leaks (15%, 14/93), and were equally prevalent after simple (15%, 2/14) or complex (15%, 12/79) operations. Small bowel obstruction caused 8 deaths, exclusively after complex operations. 5 of these involved the bypassed biliopancreatic limb and were defined as "bypass obstruction".

A spread-sheet study of cause of 30-day postoperative death revealed a rapidly lethal initiating complication of Roux-en-Y gastric bypass obstruction that requires the earliest possible recognition and treatment. Bypass obstruction needs a name and code to facilitate recognition, study, prevention and early treatment. Spread-sheet pattern analysis of all available data helped identify the initiating cause of death for individual patients when multiple data elements were present.

The number of patients undergoing surgery for the treatment of obesity, and the proportion of the health care budget dedicated to this health problem, is growing exponentially. There are several competing surgical approaches for the management of morbid obesity. We review the literature relating to four of these: gastric bypass, biliopancreatic diversion, gastric banding, and gastric pacing. Our review finds that while enhancing the malabsorptive activity of these procedures may induce an incremental increase in excess body weight loss, the proportion of patients who fail to lose more than 50% of their excess body weight is similar no matter how radical is the surgery performed. There is little guidance from the literature as to appropriate patient selection for the varying procedures, and anonymously reported registries have yet to show that patients who undergo bariatric surgery have enhanced longevity. To date, the bariatric surgical community has not conducted adequately powered randomized prospective trials to elucidate key elements of the surgical procedure such as optimal bypass length, to determine whether mixed operations are superior to those that offer intake restriction only, and to define what constitutes success after bariatric surgery. As a public health measure, bariatric surgery in the United States is being pursued in an irrational manner, being concentrated in areas where there are fewer morbidly obese patients, and used disproportionately among the population of white obese females.

Obesity in the United States poses a tremendous health risk to approximately one third of the population. As this epidemic grows, the number of bariatric surgeries performed will also increase. Although obesity itself is not gender specific, 85% of bariatric surgeries are performed in women. This article reviews some of the commonly performed weight-reduction surgeries and their associated complications. Particular emphasis is placed on the diagnostic and therapeutic implications of endoscopy in this population.