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Background and Aims: Roux-en-Y gastric bypass (RYGB) is associated with gastrojejunal (GJ) strictures in up to 20% of patients. Surgical revision of the GJ anastomosis is technically challenging and carries significant morbidity, making endoscopic therapies such as endoscopic balloon dilation (EBD) and stent placement the preferred approach. In addition, the angulation of GJ anastomosis relative to the Roux limb can cause obstructive symptoms, which are less amenable to EBD or stent placement. In patients with refractory strictures and/or angulation, we evaluate the safety and feasibility of a new anastomosis EUS-guided gastroenterostomy as an alternative to surgical revision. Methods: In patients with refractory GJ strictures and/or angulation, a new anastomosis EUS-guided gastroenterostomy between the gastric pouch and Roux limb is created. Results: Our case series includes 6 patients with a history of RYGB referred for management of obstructive symptoms. Upper endoscopy revealed severe GJ stenosis in 2 patients, complete obliteration of GJ anastomosis in 1 patient, stenosis with angulation in 1 patient, and angulation only in 2 patients. Four patients underwent previous unsuccessful attempts at balloon dilation. Lumen-apposing metal stent (LAMS) placement was initially performed in 4 patients, resulting in resolution of symptoms. However, their symptoms recurred after LAMS removal. EUS-guided anastomosis between the gastric pouch and Roux limb was created successfully in all patients, with no major adverse events. One patient experienced LAMS migration after 54 days. Patients had complete resolution of symptoms after the new anastomosis anastomosis was created. Conclusions: Our case series highlights the safety and feasibility of EUS-guided gastroenterostomy as an alternative to surgical revision in such patients. Large prospective studies with longer follow-up are needed to assess long-term outcomes of this intervention.

Background and Aims: Fully covered self-expandable metal stents are commonly used for managing GI adverse events like perforations, leaks, fistulas, and strictures. Although effective, stent length and migration can be a limitation when dealing with larger defects. Over-the-scope clips and over-the-scope suturing can be used to mitigate migration risk; however, their role is limited for stent-to-stent suturing to create longer stents. We present a novel application of through-the-scope suturing (TTSS) system for creating longer stents to manage larger GI defects. Methods: We demonstrate using a video case series the applicability of TTSS for fixing multiple coaxially placed stents to create a longer stent and simultaneously anchor them to underlying GI wall to mitigate stent migration. Results: We illustrate our success in managing 3 cases of large esophageal and/or gastric pathologies (stenosis and leak) using the TTSS system to create longer stents through stent-in-stent fixation. Conclusions: TTSS is a novel endoscopic suturing platform that is compatible with most endoscopes and can be navigated to challenging narrow and angulated location, giving it an advantage over over-the-scope suturing/over-the-scope clips. Our case series demonstrates that stent-in-stent fixation of multiple fully covered self-expandable metal stents to create longer stents using the TTSS system is an effective technique when managing larger GI defects.

A 76-year-old Caucasian male with a history of rheumatoid arthritis, Raynaud’s phenomenon, pulmonary embolism on warfarin, and a previous amputation of his left partial ring and fifth finger presented with acute onset of rash in bilateral lower extremities. He was recently started on trimethoprim-sulfamethoxazole due to concern for cellulitis. Differential diagnosis for acute-onset rash with the patient’s history presented as a challenge to the internist, as the differential is broad. Our case goes through the differential diagnosis to contrast the different presentations of rash in a patient with vasculitis. Ultimately skin biopsy in conjunction with a past positive cryoglobulinemic level helped confirm the diagnosis of cutaneous vasculitis, following which he was started on appropriate treatment and recovered.