Internal EUS-Directed Transgastric ERCP (EDGE): Game Over

Abstract

s the prevalence of obesity in the United States Aexceeds 30%, the number of bariatric procedures being performed, including Roux-en-Y gastric bypass (RYGB), is steadily increasing. Therefore, gastroenterologists will inevitably be required to manage pancreaticobiliary diseases in more patients with altered anatomy. Various techniques including deep enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopy-assisted ERCP have been developed to address the anatomic challenges of these patients. However, they are not without their limitations. Technical success rates of enteroscopy-assisted ERCP have been reported to be as low as 63% in multicenter trials. Alternatively, whereas laparoscopy-assisted ERCP has high technical success rates, it carries significant risk of complications and is more costly. Therefore, efforts by endoscopists have been focused on gaining endoscopic access to the excluded stomach to perform conventional antegrade ERCP. A recently published case series described using deep enteroscopy to achieve gastrostomy access. Our group has recently published a technique utilizing endoscopic ultrasonography (EUS) to gain gastrostomy access, but was performed in 2 stages. The procedure was coined EUSdirected transgastric ERCP (EDGE). The ideal procedure would be one that can be performed by a single team, with a high technical success rate, in a single session, in a minimally invasive fashion. With the recent Food and Drug Administration approval of a novel, fully covered, lumen-apposing metal stent (AXIOS; XLumena, Mountain View, CA) this procedure is now possible. This case report describes the first entirely endoscopic internal EDGE procedure using a lumenapposing metal stent to create a gastrogastric fistula in a RYGB patient to perform single-session antegrade ERCP.