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Create a Free AccountProcedures - Stent placement
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.Cholangioscopy-guided double-guidewire technique for complex malignant hilar obstruction
Most patients with hilar cholangiocarcinoma are unresectable at initial presentation, and endoscopic stent placement is widely performed for palliation.1 Normalization of bilirubin is associated with improved survival, and draining more than half of the liver volume is associated with fewer episodes of cholangitis.2 Obtaining optimal liver drainage typically requires a single stent in patients with Bismuth type I to II strictures and multiple stents in patients with Bismuth type III to IV strictures, while avoiding atrophic liver segments.A purely endoscopic management approach for Type V Mirizzi syndrome
A cholecystocolonic fistula (CCF) is a communication between the gallbladder (GB) and the colon. When it coexists with any type of Mirizzi syndrome (MS), this is referred to as Type V MS.1 When it is symptomatic, surgical treatment with cholecystectomy, fistula takedown, and possible colonic resection is indicated.2,3 The role of treatment in asymptomatic patients is unclear. Endoscopic management has not been described.Percutaneous transcystic cholangioscopy-assisted rendezvous ERCP in a hostile abdomen
A 74-year-old man with a history of perforated peptic ulcer disease treated with Billroth II partial gastrectomy presented with sepsis due to obstructing choledocholithiasis. He had recently undergone exploratory laparotomy and Roux-en-Y reconstruction for suspected visceral perforation, although none was identified. He was ultimately diagnosed with acute biliary peritonitis, and a percutaneous cholecystostomy (PC) tube was placed. An enteroscopy-assisted ERCP (EA-ERCP) was arranged.Simultaneous double gastrojejunostomy for afferent and efferent limb syndromes
Afferent and efferent limb syndromes are potential adverse events after partial gastrectomy with a gastrojejunostomy (GJ) reconstruction. Mechanical obstruction of the reconstructed small-bowel loops is often the underlying etiology, and it occurs because of anastomotic narrowing, postsurgical adhesions, and recurrence of the primary disease.1 Afferent limb syndrome usually presents with abdominal pain, bilious vomiting, and cholestasis and may require urgent surgical intervention in the acute setting to prevent bowel necrosis.Lumen-apposing metal stent for the management of intramural hematoma of the GI tract
GI intramural hematomas are uncommon and usually occur in the esophagus or the duodenum, and in rare cases they occur in the stomach.1 The most common cause is blunt abdominal trauma; other causes include endoscopic interventions, peptic ulcer disease, and pancreatitis; in very rare cases they can occur spontaneously in patients receiving oral anticoagulants.2,3 We present the management of 2 cases of gastric and duodenal intramural hematomas by the use of lumen-apposing metal stents (LAMSs).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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