Background

A 57-year-old woman with a history of distal Roux-en-Y gastric bypass reversal due to malnutrition initially presented for repeat Roux-en-Y gastric bypass for weight loss. A linear staple gastrojejunostomy (GJ) anastomosis was completed without intraoperative leak. This was later complicated by an acute dehiscence that did not respond to endoscopic stenting, ultimately prompting a GJ surgical revision. On post-operative day five, following robotic revision with handsewn GJ, she was admitted with fever, abdominal pain, and CT scan identified a gastric pouch leak. On endoscopy, a large dehiscence of her GJ (Figure) was deemed too large for isolated placement of a fully covered self-expanding metal stent (FCSEMS). Alternatively, isolated endoscopic vacuum-assisted closure (EndoVAC) therapy was thought to be high-risk for GJ stenosis formation. Therefore, the decision was made to utilize both FCSEMS and EndoVAC. A 23mm x 150mm FCSEMS was placed with the proximal end in the gastric pouch and distal end in the jejunum and affixed with endoscopic sutures. An EndoVAC was placed into the defect alongside the FCSEMS to bridge the dehiscence. The EndoVAC was exchanged every 3-4 days and removed after 20 days and the FCSEMS removed after two months. Follow-up upper GI series showed no further obstruction or leak. Patient was doing well at eight-month follow-up.