Gastric Access Temporary for Endoscopy (GATE): An Algorithmic Approach Towards LAMSAssisted Temporary Reversal of Gastric Bypass Anatomy to Perform Foregut Procedures Presidential Poster Award

Abstract

Introduction: Performing endoscopic foregut procedures in patients with Roux-en-Y gastric bypass anatomy is often technically difficult. Historical options include device-assisted enteroscopy and surgically-assisted transgastric access. EUS-Directed trans-Gastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has been described for ERCP in this population; however, there is concern for possible gastric fistula following LAMS removal. We describe an algorithmic approach(Gastric Access Temporary for Endoscopy (GATE)) for LAMS-assisted temporary reversal of bypass anatomy that minimizes gastric fistula formation and facilitates a variety of endoscopic procedures. Methods: Study design: Retrospective analysis of prospectively collected data at a single academic center. GATE access/removal: A linear or forward viewing therapeutic EUS scope was used. Based on anatomy, jejunum-to-gastric remnant or gastro-gastric access was created [Figure 1 and 2].The remnant stomach was accessed using a 19-G FNA needle and filled with saline/contrast. A 0.035” guidewire was advanced into the remnant stomach and the FNA needle removed. Using cautery enhanced delivery, a 15 mm x 10 mm LAMS stent was placed and dilated to a minimum of 15 mm. The indicated foregut procedure (ERCP, EUS, ESD, suturing) was then performed via the LAMS. LAMS removal using forceps occurred at the end of the procedure or at a later date [Figure 2], and a double pigtail stent (5 Fr or 10 Fr) was deployed in its place [Figure 3]. Access closure was confirmed by endoscopy and fluoroscopy.768_A Figure 1. Visualization of possible access sites for GATE in RYGB anatomy. (A) Endoscopic route of duodenoscope without LAMS access to engage the ampulla under RYGB anatomy. (B), (C), and (D) illustrate the path of the duodenoscope when a LAMS is placed under EUS guidance, providing access to the remnant stomach from either the gastric pouch, blind limb, or Roux limb respectively.768_B Figure 2. Algorithmic Approach for Patients Undergoing GATE768_C Figure 3. Endoscopic Images of GATE access, removal, and confirmation of fistula closure. (A) Lumen apposing metal stent deployed at fistula tract with guidewire still in place, (B) plastic double pigtail stent in position at fistula tract present in the gastric pouch (circled in red), several weeks after LAMS exchange, and (C) same location of the prior fistula tract having completely closed after stent removal.Results: 10 patients received the GATE procedure from May 2017 to June 2018. GATE access and removal were successful in 10/10 (100%) of patients. Foregut procedure included ERCP in 7, EUS/ERCP in 2, and ESD/suturing in 1. Gastric and jejunal access points for LAMS deployment were 30 and 70% respectively. Total procedure time per patient, including LAMS deployment, indicated procedure, and all follow-up, averaged 3.68±0.88 hours. 2 patients (20%) had complications that completely resolved after conservative management. For patients with complete follow-up (n=7), fistula closure rate was 100%. Conclusion: GATE allowed a variety of foregut endoscopic procedures in gastric bypass anatomy with successful closure in all patients. LAMS exchange to a smaller double pigtail stent appears safe and may minimize risk of residual fistula. This procedure is technically challenging and currently should be performed at centers with LAMS experience.