Laparoscopic Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric surgical procedures performed in Michigan and throughout the United States [1,2,3]. RYGB has demonstrated significant success in promoting weight loss, leading to remission of medical comorbidities, and improving quality of life [4]. RYGB involves creating a small gastric pouch with a gastrojejunal anastomosis which thereby excludes a large portion of the stomach and duodenum (Fig. 1). By excluding a portion of the gastrointestinal system, weight loss is attained through multiple mechanisms including restricted consumption of food, reduced absorption of ingested nutrients, and modification of gastrointestinal hormones that effect satiety and hunger. Following RYGB, endoscopic access to the excluded gastric remnant and biliopancreatic limb is precluded due to altered anatomy, although balloon-assisted enteroscopy and endoscopic ultrasound may provide potential options for access [5, 6].

Fig. 1
figure 1

Roux-en-Y Gastric Bypass Procedure. A small gastric pouch is created, followed by a gastrojejunostomy. A jejunojejunostomy is then performed and the Y-type enterostomy created.

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Complications relating to RYGB may necessitate the need for access to the gastric remnant and biliopancreatic limb for diagnostic evaluation or therapeutic purposes. Gastric remnant access for postoperative delayed gastric emptying/biliopancreatic obstruction and for malnutrition related to RYGB have both been previously described [7, 8]. Nosher et al. described the placement of a venting gastrostomy in 8 patients who developed obstruction or ileus following RYGB. Additionally, Stein et al. reported their experience in placing computed tomography (CT)-guided gastrostomy tubes in the treatment of RYGB-related malnutrition. Gastrostomy placement for nutritional support in conditions unrelated to a patient’s RYGB has not been previously reported in the literature. Additionally, long-term follow-up data for this patient population are not available. As the population of patients with RYGB grows and ages, we anticipate a commensurate increase in requests for gastrostomy tube placement in these patients. Here, we present our 13-year experience and success rates with percutaneous gastrostomy placement in patients with a history of RYGB.

Materials and methods

After institutional review board approval, a retrospective review of our institution’s electronic medical record system and picture archiving and communications system was performed in an effort to identify all RYGB patients who underwent attempted percutaneous gastrostomy placement between April 2003 and November 2016. These procedures were performed using fluoroscopy, ultrasound with fluoroscopy, or CT. All patients who received an initial gastrostomy tube placement and had a history of RYGB were included. Data collection was performed in compliance with the Health Insurance Portability and Accountability Act and tabulated in spreadsheet format (Excel; Microsoft, Redmond, WA). Technical success was defined as placement of a functional gastrostomy tube into the excluded remnant lumen. Complications were classified as minor or major using the Society of Interventional Radiology Clinical Practice Guidelines [9]. The focus of this retrospective review was to document complications related to gastrostomy placement. Therefore, complications relating to subsequent tube malfunction or dislodgement not resulting in peritonitis were excluded.

Technique

Gastric remnant gastrostomy placement was performed utilizing several imaging guidance techniques including fluoroscopy, ultrasound with fluoroscopy, or CT. Gaseous distension of the stomach is typically required to assess the stomach for safe access and then to complete the procedure. For RYGB patients, gastric remnant access for gaseous distension is achieved via small gage needle (20 or 22G Chiba Biopsy Needle, Cook Medical, Bloomington, IN). Intragastric location of the needle is confirmed with contrast injection. When the gastric remnant already contains gas, or is fluid-distended, needle access to the gastric remnant is achieved using fluoroscopic guidance alone. If the gastric remnant is not discernible with fluoroscopy, needle access is achieved using ultrasound with fluoroscopy or CT guidance. Once gastric remnant access is achieved, air is injected to distend the gastric lumen either directly via the needle, or the needle can be exchanged over a wire for the 4F inner cannula from a Neff set (Cook Medical). When access is established using fluoroscopy or ultrasound with fluoroscopy, the procedure is completed with fluoroscopic guidance. When access is achieved with CT, the procedure is completed with CT guidance. At exam completion, the inflation needle (or Neff set cannula) is removed.

Once the gastric remnant is gas distended, a suitable access window (i.e., no intervening bowel or liver) is chosen. Care is taken to select a site that is at least 1–2 cm away from the costal margin or xyphoid process. Two small (5-mm) skin incisions are made at the chosen access site a few millimeters apart. Through the first incision, the 17G needle from a suture anchor set (Cope Gastrointestinal Suture Anchor Set, Cook Medical) is passed into the stomach. A gastric suture anchor is deployed into the stomach via the needle. Through the same incision, the needle is again passed into the stomach and a second suture anchor is deployed. The anchor sutures are pulled snugly, approximating the anterior stomach to the abdominal wall, and the anchor sutures are then tied together and the knot is buried deep to the skin surface. Through a second small incision, the 17G needle is again passed into the stomach, this time as close as possible (ideally between) to the two anchors. A guidewire is inserted (Amplatz Ultra Stiff Wire Guide, Cook Medical), the tract is sequentially dilated, and a 14F pigtail-retained gastrostomy tube (Wills-Oglesby, Cook Medical) is placed. This is the standard tube used at our institution because of operator familiarity and ease of placement. Pigtail-retained gastrostomy tubes are placed for both decompression and tube feedings. Gastric decompression can commence immediately, while tube feeding is started after 24 h. The tubes are exchanged as needed when damaged, occluded, leaking, or dislodged. Tube follow-up is typically performed by the referring surgical service.

Results

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. The mean age was 51.2 years (range 29–75 years). Insufflation of the gastric remnant was performed via a clear window (n = 35), transhepatic (n = 5), and transjejunal (n = 1) routes. 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). Overall, the procedure was technically successful in 39 of the 41 cases (95%). Case numbers 2 and 21 are the same patient who presented in the early postoperative period with delayed gastric emptying and then again several years later with malnutrition related to RYGB. Cases 15, 16, and 17 are the same patient whose initial tube was placed for malnutrition related to RYGB, but because of early dislodgement (at 8 days), a separate insertion procedure was required. Then, nearly a year following removal of her initial tube, she again required gastric remnant gastrostomy for malnutrition related to RYGB.

Gastrostomy placement for decompression in the setting of delayed gastric remnant emptying/biliopancreatic limb obstruction was technically successful in all eight cases (Table 1). Seven cases presented in the early postoperative period at a mean of 8.7 days (range 3–19 days) from time of surgery, while one case presented nearly a year after RYGB (329 days). Fluoroscopy (n = 4), ultrasound with fluoroscopy (n = 1), and CT (n = 3) were used for image guidance. Six of the eight cases were managed conservatively following placement, and the tubes were removed by the surgical service when the patient’s condition improved. Cases 1 and 8 had persistence of symptoms that prompted surgery for lysis of adhesions, at which time the tube was removed. Tube removal occurred after a mean of 33.6 days (range 3–78 days) in this subgroup.

Table 1 Patients presenting with delayed gastric remnant emptying/biliopancreatic limb obstruction
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Gastrostomy placement for RYGB-related malnutrition was technically successful in all 17 cases (Table 2). These patients presented months to years after surgery with chronic emesis or chronic abdominal pain causing anorexia. CT (n = 13) and ultrasound with fluoroscopy (n = 4) were used for image guidance. One patient was lost to follow-up and one patient still has a tube at this time. In the remaining 15 cases, tube removal occurred after a mean 97.7 days (range 8–239 days). Tube removal was performed after adequate oral intake was maintained.

Table 2 Patients presenting with malnutrition directly related to RYGB
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Gastrostomy placement for nutritional support for conditions unrelated to RYGB was technically successful in 13 of 15 cases (Table 3). Case 28 was unsuccessful despite adequate insufflation due to lack of a clear access window for tube placement. Case 34 was unsuccessful due to an inability to access the gastric remnant for insufflation. Indications included ventilator-dependent respiratory failure, neurologic conditions precluding oral intake, and malnutrition secondary to malignancy. CT (n = 9) and ultrasound with fluoroscopy (n = 6) were used for imaging guidance, with case 34 failing both ultrasound with fluoroscopy and CT. Two patients were lost to follow-up, two entered into hospice care, and two cases still had the tube in place at the time of writing. For the remainder, tube removal occurred after a mean 90 days (range 4–353 days).

Table 3 Patients presenting for nutritional support for conditions unrelated to RYGB
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Gastrostomy placement to provide access for ERCP evaluation of biliary ductal dilatation occurred in one case and was performed with ultrasound with fluoroscopy guidance. A 14F gastrostomy tube was initially placed, followed by upsizing to 18F and then 24F at 2 and 4 weeks, respectively. At the time of ERCP, general surgery performed dilation of the track to 16 mm (equivalent to 48F) in the endoscopy suite. The patient developed acute pancreatitis following ERCP and the tube was removed at 149 days.

Five complications were encountered: 4 classified as ‘Major’ (9.8%) and 1 classified as ‘Minor’ (2.4%) following the Society of Interventional Radiology guidelines. The most significant major complication was early tube dislodgement in one patient with resultant intraperitoneal feeds requiring laparotomy (Fig. 2). On retrospective review, it is believed that there was a failure of gastropexy that prompted tube dislodgement and leak. Malnourished patients have reduced healing and may be at an increased risk for gastropexy failure. Upper gastrointestinal bleeding, which occurred in one patient 2 weeks following tube placement, may have been related to the procedure or may have been related to stress ulceration associated with the intercurrent illness. Early tube dislodgement requiring repeat intervention occurred in one patient. Case 23 developed intractable pain following the procedure. The gastrostomy tube was placed high in the abdomen, slightly lateral to the xyphoid process in an attempt by the interventionalist to avoid crossing a Marlex mesh-wrapped gastric pouch. Case 41 developed cellulitis approximately 1.5 months following ERCP, which resolved with antibiotics. There were no procedure-related deaths.

Fig. 2
figure 2

A 53-year-old woman with worsening leukocytosis 4 days after placement of a percutaneous gastrostomy tube. Axial contrast-enhanced computed tomography with water soluble contrast administered through the gastrostomy tube demonstrates an extraluminal gastrostomy tube, free air, and perihepatic water soluble contrast material.

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Discussion

Gastrostomy tubes placed by interventional radiology help to avoid the risks of surgery and general anesthesia. Radiologic gastrostomy placement in conventional anatomy is associated with a relatively low major complication rate of 5.9% [10]. Although percutaneous gastrostomy placement in RYGB anatomy is more technically challenging than cases with conventional anatomy, a significant increase in the overall rate of major complication was not encountered in our series (7.3%). No additional factors that increase risk or new risks were identified.

We encountered a group of bariatric patients requiring long-term enteral feeding for nutritional support for conditions unrelated to RYGB. Indications included ventilator-dependent respiratory failure, neurologic conditions precluding oral intake, and malnutrition secondary to a malignancy. Similar to patients treated for RYGB-related malnutrition, feeding through the gastric remnant was preferred. The gastric pouch is extremely small, typically around 30 ml just below the esophagus, and connected to the jejunum. Placing a gastrostomy tube here is contraindicated for several reasons: risk of leak, inability to bring gastric pouch up to the abdominal wall, inability to bolus feed and risk of aspiration, and no benefit in terms of absorption (gastric remnant feeds flows into duodenum and proximal small intestine that is bypassed with full absorption potential). To the best of our knowledge, no previous report has described the role and safety of gastric remnant gastrostomy for nutritional support during management of conditions unrelated to a patient’s RYGB.

Delayed gastric remnant emptying and biliopancreatic limb obstruction may develop in the early (days to weeks) or late postsurgical period. In the early postsurgical period, this complication may arise from ileus or mechanical obstruction secondary to adhesions, internal hernia, or hemorrhage or edema at the enteroenterostomy. If left untreated, the resultant high intraluminal pressures may result in ischemia, anastomotic/staple line disruption with leak, or perforation (Fig. 3). Anastomotic or staple line leaks are one of the most serious complications following RYGB with a mortality rate approaching 50% [11,12,13]. Findings of delayed gastric remnant emptying and biliopancreatic limb obstruction on radiographs and CT scans include distention of the remnant stomach and biliopancreatic limb with occasional air fluid levels [14, 15].

Fig. 3
figure 3

A 51-year-old woman with fever and leukocytosis 11 days after Roux-en-Y gastric bypass. Axial and coronal contrast-enhanced computed tomography demonstrates a markedly dilated gastric remnant with increased fluid adjacent to the staple line, concerning for leak/impending rupture.

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RYGB-related malnutrition develops later in the postsurgical period (months to years) and may be a consequence of chronic abdominal pain causing anorexia, chronic emesis, stomal stenosis, or stomal ulceration. Stomal stenosis typically occurs at the gastrojejunal anastomosis with an estimated incidence of 4%–27%, while marginal ulcers at the anastomosis can occur in up to 16% of patients [16]. Enteral feeding through the excluded remnant is the preferred route for treating protein–calorie and vitamin deficiencies until oral intake is tolerated.

Remnant gastrostomy placement for access to allow for a transgastric ERCP has been described in the literature previously [17]. Tekola et al. described the placement of a surgical gastrostomy tube and performance of ERCP through the healed, mature gastrostomy tract. Additionally, gastrostomy placement may also allow for transgastric endoscopic evaluation of RYGB postoperative bleeding or stress ulceration. Although not observed in our patient cohort, remnant gastrostomy placement may be applicable for venting in the setting of malignant gastric outlet or bowel obstruction.

The type of imaging guidance utilized is dependent on pre-procedural imaging and operator experience. In cases of delayed gastric remnant emptying/biliopancreatic limb obstruction, pre-procedural imaging typically demonstrates a dilated gastric remnant, which may allow simple access using fluoroscopy alone. In cases where there is under-distension of the gastric remnant, access using ultrasound with fluoroscopy or CT is employed. Early in our series, a dedicated CT unit was not available to the vascular and interventional radiology division for procedures, and cases were typically performed using fluoroscopy or ultrasound with fluoroscopy. When our division gained access to a dedicated scanner for procedures, most cases were performed using CT.

Our study is limited by retrospective design and a small patient cohort from a single institution. Other limitations include potential lack of notification of complications although we have a large health system with several hospitals and an interconnected electronic medical record. However, we believe that percutaneous gastric remnant gastrostomy placement is a safe and reliable procedure in patients with a history of RYGB. Indications for placement included delayed gastric remnant emptying/biliopancreatic obstruction, malnutrition related to RYGB, nutritional support for conditions unrelated to RYGB, and access to allow for transgastric ERCP. 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.