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A patient with a history of Roux-en-Y gastric bypass surgery in 2003 and cholecystectomy in 2017 was transferred for evaluation of biliary-type abdominal pain and abnormal liver test results. Abdominal US scan demonstrated a dilated bile duct measuring 1.4 cm and choledocholithiasis (Fig. 1). Upper endoscopy confirmed normal Roux-en-Y anatomy, and an EUS-directed transgastric ERCP procedure was planned.
Figure 1Abdominal ultrasound view demonstrating a dilated bile duct with choledocholithiasis.
Under EUS guidance, a 15- × 10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS; Axios; Boston Scientific, Marlborough, Mass, USA) was placed from the gastric pouch into the jejunal limb just beyond the gastrojejunal anastomosis (Fig. 2).
Figure 2Endoscopic view of the lumen-apposing metal stent position just beyond the gastrojejunal anastomosis.
Three weeks later, a duodenoscope was advanced to the LAMS but was unable to traverse the LAMS because of significant looping in the gastric pouch and jejunual limb (Fig. 3). Various maneuvers were used to aid duodenoscope passage, including advancing the duodenoscope over a 0.035-inch × 450-cm stiff guidewire (Jagwire; Boston Scientific), abdominal counterpressure, patient repositioning, and the use of a therapeutic gastroscope with a distal cap to attempt biliary cannulation, but all maneuvers were unsuccessful.
Figure 3Fluoroscopic view of duodenoscope looping in the gastric pouch and jejunal limb.
Finally, a 0.035-inch × 450-cm stiff guidewire was endoscopically placed into the gastric remnant, and the endoscope was removed. A 50-cm × 19.7-mm gastric overtube device (Guardus gastric overtube; US Endoscopy, Mentor, Ohio, USA) was advanced under flouroscopic guidance over the guidewire immediately beyond gastrojejunal anastomosis and in close proximity to the jejunal end of the LAMS. The duodenoscope was then advanced through the gastric overtube. With the gastric overtube in place, the duodenoscope was able to easily traverse the LAMS and was advanced to the duodenum (Fig. 4).
Figure 4Fluoroscopic view of the gastric overtube, lumen-apposing metal stent, and duodenoscope position.
Subsequently, ERCP with cholangioscopy (SpyGlass; Boston Scientific) was successfully performed, brushings and biopsies of a distal bile duct stricture were performed, stone fragments were removed, and a fully covered 10-mm × 8-cm metal biliary stent (Viabil; W.L. Gore, Flagstaff, Ariz, USA) was placed. Pathology confirmed benign inflammatory cells, and biliary metal stent removal after 4 weeks was planned.
In conclusion, gastric overtube use aided duodenoscope passage during the EUS-directed transgastric ERCP procedure by preventing duodenoscope loop formation in the gastric pouch and jejunual limb.
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