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EUS-directed transgastric ERCP in Roux-en-Y gastric bypass revision of sleeve gastrectomy
EUS-directed transgastric ERCP (EDGE) is an effective approach for the treatment of biliary adverse events of patients who have undergone Roux-en-Y gastric bypass (RYGB).1 Through deployment of a lumen-apposing metal stent (LAMS) from the gastric pouch into the excluded stomach, EDGE allows access to the bypassed stomach and duodenum in patients who have undergone RYGB (Fig. 1). However, patients who have undergone sleeve gastrectomy (SG) who undergo revision to RYGB have limited working space within both the gastric pouch and excluded stomach (Fig. 2), making therapeutic endoscopic procedures such as EDGE technically challenging.Endoscopic through-the-scope suturing
There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine.Cardiac septal occluder for closure of persistent gastrogastric fistula
A 53-year-old man with diabetes mellitus and a history of Roux-en-Y gastric bypass had a bile leak after a cholecystectomy in March 2020. He subsequently underwent EUS-directed transgastric ERCP (EDGE) with gastrogastric fistula creation with a lumen-apposing metal stent (LAMS) (AXIOS, Boston Scientific, Marlborough, Mass, USA) followed by placement of a 10F × 10-cm plastic biliary stent in March 2020.Management of adverse events of EUS-directed transgastric ERCP procedure
Accessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period.An adverse event of EUS-directed transgastric ERCP: stent-in-stent technique to bridge the peritoneal gap
A 49-year-old woman with a history of Roux-en-Y gastric bypass surgery was referred because of elevated liver enzymes, right upper-quadrant abdominal pain, and a dilated common bile duct on MRCP. The options for biliary access were discussed with the patient, including laparoscopy-assisted ERCP, enteroscopy-assisted ERCP, and EUS-directed transgastric ERCP (EDGE). She opted to proceed with an EDGE, in which a lumen-apposing metal stent (LAMS) is used to create a gastrogastrostomy to facilitate ERCP with a duodenoscope.Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP
Until recently, patients with Roux-en-Y gastric bypass had the options of enteroscopy-assisted or surgery-assisted ERCP.1 However, the use of a lumen-apposing metal stent (LAMS) with EUS to create a transgastric fistula allows for ERCP with a duodenoscope (EUS-directed transgastric ERCP [EDGE]).2 However, dislodgement of the LAMS with advancement of the endoscope can result in a perforation, leading some providers to do this in 2 stages: LAMS placement followed by fistula maturation (7-14 days) and subsequent ERCP.
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