2191 EUS-Directed Transgastric ERCP (EDGE) for Removal of Cystic Duct Coils: A Novel Application of an Emerging Technique

Abstract

INTRODUCTION: Presence of obesity as well as sudden weight loss, both predispose to gallstone disease. Post roux-en-y gastric bypass (RYGB) anatomy creates additional challenges for endoscopy and surgery. We present a captivating case of post-RYGB complicated gallbladder (GB) surgery, which eventually ends with coiling of cystic duct. The coil formed a nidus for infection and biliary obstruction, and the novel technique of EUS directed trans-gastric ERCP (EDGE) comes to the rescue. CASE DESCRIPTION/METHODS: A 27-year-old male with morbid obesity underwent RYGB. Over next 6 months, he lost 130 lbs (35% of total body weight). Three years after RYGB, he presented with acute calculous cholecystitis; requiring laparoscopic-converted to open cholecystectomy due to gangrenous GB and extensive adhesions. Postoperatively, a large cystic duct leak developed, requiring percutaneous transhepatic biliary drainage. Due to persistent leak IR-guided coil embolization of the cystic remnant was successfully done.After three years he presented again with RUQ pain, nausea and fever. CT showed cystic duct coil migration into the CBD with upstream dilation. An EDGE procedure with a 20 mm lumen apposing metal stent was performed with successful biliary sphincterotomy and biliary stones and sludge removal. The migrated coils were removed with a rotating action of the biopsy forceps advanced intraductally which facilitated wrapping of the coils around the forceps, and then removed with a snare. DISCUSSION: Obesity pauses high risk for cholelithiasis due to change in fat metabolism, hormonal regulation and GB motility. Significant weight loss further leads to gallstone formation. Our patient presented with acute calculous cholecystitis. Cholecystectomy was complicated by bile leak and led to percutaneous biliary (PTC) drainage. Lap-assisted ERCP could not be performed due to high risk of morbidity in this patient. Instead of PTC and coil placement, EDGE may have been a better option at that point. Patient ended up requiring EDGE due to development of cholangitis associated with biliary obstruction due to migrating cystic duct coils. In this complicated young patient with abdominal adhesions, EGDE was a saving grace, as the alternative may be to live with PTC drain lifelong.