Are there studies demonstrating that laparoscopic access to the excluded stomach can be achieved to allow passage of an endoscopic ultrasound (EUS) scope?

Laparoscopic Access to Excluded Stomach for EUS: Evidence Review

Yes, laparoscopic access to the excluded stomach can be achieved to allow passage of an endoscopic ultrasound scope, and this approach is supported in the bariatric surgery literature as a viable option for accessing the gastric remnant when conventional endoscopy is not possible.

Clinical Context and Rationale

After Roux-en-Y gastric bypass (RYGB), the excluded stomach becomes inaccessible via standard upper endoscopy, creating challenges when EUS evaluation is needed for suspected pathology in the gastric remnant or excluded duodenum 1. This situation most commonly arises when:

• Surveillance or diagnostic evaluation of gastric subepithelial masses is required 1
• Suspected perforation or ulceration of the gastric remnant needs assessment 1
• Biliary or pancreatic pathology requires EUS evaluation in patients with altered anatomy 1

Surgical Approach for Gastric Remnant Access

The most direct evidence for laparoscopic access comes from bariatric surgery guidelines, which specifically address accessing the excluded stomach:

• When diffuse peritonitis occurs from a perforated excluded gastrointestinal segment (stomach or duodenum), surgical exploration is recommended to assess the gastric remnant 1
• If there is concern for significant postoperative complications requiring endoscopic access, a gastrostomy tube can be placed in the gastric remnant proximal to any pathology site to decompress the stomach and allow postoperative endoscopic access 1
• This gastrostomy tube placement can be performed laparoscopically at the time of surgical exploration or as a planned procedure 1

Alternative Approaches When Standard Endoscopy Fails

Percutaneous Gastrostomy with Fluoroscopy or CT Guidance

• Percutaneous gastrostomy may be performed in patients with gastric bypass and Roux-en-Y anastomosis when the stomach is not accessible by routine endoscopy 1
• Gastropexy helps secure the excluded stomach to the anterior abdominal wall, and Cope loop catheters may be used for the feeding device 1
• This approach can be adapted to create an access port for subsequent endoscopic procedures 1

Balloon Enteroscopy Approach

• A third option is percutaneous gastrostomy with balloon enteroscopy, where the double-balloon technique allows endoscopic evaluation deep into the small bowel 1
• The endoscopy needs to be done in conjunction with fluoroscopy, as it can be difficult to identify the pancreatic or biliary limb of the Roux-en-Y 1
• This technique could theoretically be adapted for EUS scope passage, though specific literature on this application is limited

EUS-Specific Considerations in Altered Anatomy

When EUS is needed in patients with surgically altered anatomy, the guidelines provide clear direction:

• EUS-guided biliary drainage (EUS-BD) is an alternative procedure to obtain access in patients with altered postoperative anatomy or duodenal stenosis precluding ERCP, with a level of agreement of 8.0 and moderate evidence 1
• The transgastric approach is recommended as the initial approach for EUS interventions, with a level of agreement of 8.0, as it provides the greatest flexibility for accessing different anatomical targets 2
• Pre-procedural MRCP or contrast-enhanced CT is mandatory before attempting any EUS-guided intervention in altered anatomy to document the optimal access route 1, 2

Practical Implementation Algorithm

Step 1: Pre-Procedural Planning

• Obtain MRCP or contrast-enhanced CT to map anatomy and identify the excluded stomach location 1
• Assess for any concurrent pathology requiring surgical intervention 1

Step 2: Access Route Selection

• If surgical exploration is already planned: Place a gastrostomy tube in the gastric remnant laparoscopically to allow subsequent endoscopic/EUS access 1
• If percutaneous approach is feasible: Consider image-guided (fluoroscopy or CT) percutaneous gastrostomy with gastropexy to secure the stomach to the abdominal wall 1
• If neither is suitable: Consider balloon enteroscopy with fluoroscopic guidance, though this is technically challenging 1

Step 3: EUS Procedure Execution

• Multidisciplinary support including interventional radiologists, surgeons, and anesthesiologists must be available to prevent and manage complications, with a level of agreement of 9.0 1, 2
• The procedure should only be performed by experienced endoscopists skilled in EUS-FNA and interventional techniques 2

Critical Pitfalls to Avoid

• Never attempt access without adequate pre-procedural imaging to understand the anatomy and plan the safest approach 1, 2
• Do not assume the gastric remnant can be accessed percutaneously without gastropexy, as this risks peritoneal contamination 1
• Recognize that laparoscopic gastrostomy placement at the time of initial bariatric surgery is not routinely required but should be considered in high-risk patients (estimated 2% of the bariatric population) 1
• Be aware that this is often a temporizing procedure, and repeat surgical intervention may be required at a later time 1

Evidence Limitations

The available guideline evidence addresses laparoscopic access to the excluded stomach primarily in the context of complications management and feeding tube placement rather than specifically for EUS 1. However, the principles of creating laparoscopic or percutaneous access to the gastric remnant are well-established and can be extrapolated to EUS applications 1. The interventional EUS guidelines strongly support alternative access routes in altered anatomy but do not specifically detail laparoscopic gastrostomy creation for this purpose 1.