Novel, Durable Endoscopic Treatment Of Mucinous Biliary Obstruction From Metastatic Mucinous Colon Cancer

ID: 3527179 SWITCHING THE SWITCH: ENDOSCOPIC REVERSAL OF A BILIOPANCREATIC DIVERSION Manol Jovani*, Sarah S. Al Ghamdi, Michael Bejjani, Bachir Ghandour, Mouen A. Khashab Background: Biliopancreatic diversion (also known as duodenal switch) is a complex bariatric surgery that includes a sleeve gastrectomy and long Roux-en-Y intestinal bypass. The jejunojejunal anastomosis is very distal resulting in the bypass of twothirds or more of the intestine. Patients lose weight not only because nutrients bypass most of the intestine, thereby reducing the absorption area, but also because nutrients join the biliopancreatic secretions and enzymes only distally leading therefore to their reduced digestion and absorption. This is a very effective surgery for weight loss, but can be complicated by severe malnutrition. In such cases, surgical reversal of the duodenal switch is done by creating a proximal anastomosis between the alimentary and biliopancreatic limbs. To our knowledge, endoscopic reversal of the duodenal switch has not been reported previously. Case Report: A 43year old female with history of biliopancreatic diversion for obesity 9 years prior was hospitalized for diarrhea, malnourishment, significant weight loss (42 pounds) and failure to thrive. Numerous evaluations for neoplasia were negative. It was deemed that the patient’s malnourishment and weight loss were due her altered anatomy. Thus, considering her general condition, an endoscopic ultrasound (EUS)-guided duodenal switch reversal with lumen-apposing metal stent (LAMS) was proposed. The echoendoscope was directed with fluoroscopic guidance towards the right upper quadrant, the expected direction of the duodenal stump and biliopancreatic limb. Then, the duodenal lumen was identified with EUS, and a 19G FNA needle was used to access it. The location was confirmed with fluoroscopic imaging by contrast injection. Abundant contrast and saline was injected to clearly define the anatomy and distend the biliopancreatic limb. Once the biliopancreatic limb was clearly defined and distended, a jejunoduodenostomy was created under EUS-guidance with the freehand technique using a 20 mm x 10 mm cautery-assisted LAMS. Additionally, a percutaneous endoscopic jejunostomy (PEJ) was placed to help the patient with nutrition. The patient gained weight, and the PEJ was removed after two months. At follow-up EGD, the LAMS was patent. Currently, the patient is 6 months post-procedure, doing well and gaining weight. Conclusion: Endoscopic reversal of biliopancreatic diversion by means of LAMS is feasible. Long-term outcomes of this procedure should be explored and this method should be compared with surgical reversal.