Use of double-balloon enteroscopy to perform PEG in the excluded stomach after Roux-en-Y gastric bypass

Background: Because of postoperative complications, patients who have undergone Roux-en-Y gastric bypass (RYGB) for weight loss may require radiographic investigation of the pancreaticobiliary limb or enteral feeding. Gastrostomy-tube placement into the excluded stomach for these indications is typically performed surgically or via fluoroscopic or US guidance; PEG has not been reported as being performed for this purpose. Successful examination of the excluded stomach after RYGB has been reported when using double-balloon enteroscopy (DBE). Objective: To perform PEG in the excluded stomach by using DBE. Design: Retrospective review. Setting: Single, North American tertiary-care center. Patients: Individuals with postoperative complications after RYGB that requires radiographic examination of the excluded stomach and the pancreaticobiliary limb, or enteral feeding. Interventions: Performance of PEG within the excluded stomach by using DBE. Main Outcome Measurements: Ability to perform PEG-procedure-related complications and resultant management changes. Results: PEG was successfully performed by using DBE in 3 of 4 patients with postoperative complications after RYGB. In 2 of the cases, the results of radiographic studies performed with contrast administration through the gastrostomy tube led to significant operative management changes. In the third case, preoperative enteral nutrition was provided by using a gastrostomy tube. PEG placement was not possible in the fourth case because of the lack of abdominal transillumination. Major complications were not observed. Limitations: Small sample size, single-center experience. Conclusions: PEG placement in the excluded stomach after RYGB by using DBE was safe, technically feasible, and led to management changes in patients in whom it was performed. This procedure should be added to the growing list of indications for DBE.