2185 69-Year-Old Male After Gastric Bypass With Choledocholithiasis Treated With EDGE Procedure Complicated by LAMS Dislocation

Abstract

INTRODUCTION: With the alarming increase in the prevalence of obesity, more people are undergoing bariatric surgeries of which most common is Roux-en-Y gastric bypass (RYGB). This altered anatomy poses challenges in accessing the papilla for ERCP in the setting of biliary pathology. Until recently enteroscopy or surgery assisted ERCP were the two main treatment options. Today, EUS-directed trans-gastric ERCP (EDGE) procedures have emerged as a promising treatment option in such circumstances. CASE DESCRIPTION/METHODS: A 69-year-old male with history of RYGB, cholecystectomy, Barret’s esophagus, CAD and CKD was admitted with one day history of vomiting and RUQ abdominal pain. On initial evaluation the patient was afebrile, normotensive with scleral icterus. Labs were significant for leukocytosis (14.2 10^3/µL), elevated transaminases (AST 254 U/L; ALT 231 U/L) and signs of biliary obstruction (ALP 252 U/L; bilirubin 3.3 mg/dl). Abdominal imaging (CT, US) revealed dilated intra and extra hepatic biliary ducts with the CBD measuring 1.4cm. For further evaluation, an EDGE procedure was performed within 24 hours. After injecting water to form a fluid collection in the stomach and confirming no blood flow in the path, a 20mm Hot Axios LAMS was successfully deployed under EUS guidance. The gastric lumen was confirmed after dilatation to 18mm. The duodenoscope was advanced and subsequent cholangiogram revealed several large stone filling defects along with dilated hepatic ducts. A sphincterotomy was performed, 9-12mm followed by 12-15mm extraction balloons were advanced over the wire and after multiple sweeps, 5 large stones were removed with resolution of biliary obstruction. During the ERCP, the LAMS dislodged into the native stomach over the scope but was able to be successfully removed by rat-tooth forceps. Finally, the fistula was closed using endo-clips and the patient reported resolution of his symptoms and LFTs normalized. DISCUSSION: Choledocholithiasis after RYGB is not unusual as nearly 50% of patients develop biliary stones within two years after surgery. The most common complications after EDGE procedure are bleeding from the fistula site, persistent fistula formation, perforation or adverse events related to ERCP. We present a rare case of LAMS dislocation into the stomach during EDGE which was successfully removed with the snare. Being able to recognize and immediately treat this potential complication may help providers anticipate it during EDGE procedures.