Endoscopic Management of Malignant Gastric Obstruction after Roux-en-Y Gastric Bypass: A Case Report

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A 59-year-old male with a history of Roux-en-Y gastric bypass (RYGB) presented to the emergency department 16 years later with symptoms of intestinal obstruction, including abdominal pain, distension, vomiting, and an inability to pass stool or gas for 48 hours. Imaging revealed hepatic flexure thickening, cecal dilation, small bowel distention, and mesenteric adenopathy. The patient underwent emergency right hemicolectomy, with histopathological analysis revealing signet-ring cell carcinoma, suggesting gastric cancer infiltration by contiguity. A subsequent CT scan showed dilation of the excluded stomach and thickening of the distal gastric antrum and duodenal bulb, raising concern for gastric outlet obstruction. Due to obstructive symptoms, including persistent nausea and vomiting, an endoscopic ultrasound (EUS) was performed. EUS-guided transgastric placement of a lumen-apposing metal stent (LAMS) successfully connected the gastric stump to the excluded stomach. Balloon dilation of the LAMS allowed passage of the endoscope, confirming stenosing malignancy at the gastric antrum and allowing for drainage of the excluded stomach. One week later, a self-expanding metal stent (SEMS) was deployed across the obstruction, restoring luminal patency and enabling the patient to resume oral intake. This case highlights the role of EUS-directed transgastric intervention (EDGI) in managing gastric bypass-related complications, specifically the use of LAMS to restore gastrointestinal continuity in patients with malignant obstruction of the excluded stomach. This minimally invasive approach offers a safe and effective alternative to surgical re-intervention in appropriately selected patients. Publication History Article published online: 27 March 2025 © 2025. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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