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Create a Free AccountProcedures - ERCP/Cholangioscopy
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.The use of a rescue stent in the management of lumen-apposing metal stent migration during EUS-directed transgastric ERCP with stent-in-stent technique to remove a forgotten metal biliary stent
Roux-en-Y gastric bypass poses a unique set of challenges during ERCP. Conventional approaches include laparoscopic-assisted ERCP and balloon-assisted enteroscopy. Laparoscopic-assisted ERCP is invasive and requires coordination between a surgeon and gastroenterologist. Balloon-assisted ERCP has a lower procedural success rate (60%-80%),1 and the size of the working channel can limit interventions. EUS-directed transgastric ERCP (EDGE) (Fig. 1)2 allows for a same-day or multistep procedure by creating a gastrogastric fistula, allowing endoscopic access to the biliary tree via the excluded stomach.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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