Fig. 3. (A) Gastrostomy tube study in patient who had previously undergone Roux-en-Y gastric bypass procedure for morbid obesity. (B) Note surgical staple line (arrows). Gastrostomy was placed in conjunction with pyloric closure and duodenal ulcer oversew for a perforated duodenal ulcer. Six months later, pyloric obstruction persisted requiring ongoing gastric decompression. Following percutaneous endoscopic gastrostomy (PEG) tract dilation and access into the disconnected stomach, a balloon assisted enteroscope is placed per os to visualize the obstructed duodenum. (C) A sclerotherapy needle is used through the PEG scope to assure a safe tract into the duodenal bulb. Following balloon dilation (D), a 7 Fr double pigtail stent (arrows) is placed through the stomach into the duodenum (E). (F) Note contrast injection into the C-loop alongside the stent. (G) A 15 mm lumen-apposing stent (LAS) self-expandable metal stents (Axios; Boston Scientific, Natick, MA, USA) was subsequently placed (arrow). Note patent prosthesis (arrows) (H, I) on subsequent computed tomography scan allowing G tube removal followed by removal of the LAS 4 weeks later (J). Case is courtesy of AndrewRoss, MD, Virginia Mason Medical Center.
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