S1854 Endoscopic Retrograde Cholangiopancreatography in Patient With Roux-en-Y Gastric Bypass and High-Grade Duodenal Stricture Across Dual Lumen Apposing Metal Stents

Abstract

INTRODUCTION: Endoscopic ultrasound-guided lumen-apposing metal stents (LAMS) is a minimally invasive modality that has not only been used for drainage of pancreatic fluid collection but also other off-label indications. We demonstrated a case with multiple applications of LAMS for management of both choledocholithiasis and enteric stricture in a patient with Roux-en-Y Gastric Bypass (RYGB) anatomy. CASE DESCRIPTION/METHODS: An 82-year-old woman with a history of RYGB, multiple abdominal surgeries and choledocholithiasis, which was treated with laparoscopic-assisted ERCP (LA-ERCP) and complicated by duodenal perforation and repaired by open surgery, was admitted for right upper quadrant abdominal pain. MRCP revealed choledocholithiasis with biliary dilatation. After discussion of various options for accessing biliary system, EDGE procedure was pursued. For the initial stage, LAMS was deployed to obtain access to gastric remnant under endosonographic and fluoroscopic guidance. The patient returned in 3 weeks after the tract was mature for ERCP. However, high-grade duodenal stricture, which is likely due to post-surgical scarring or peptic stricture, was unexpectedly found before reaching the biliary system. The stricture was treated with 20 mm by 10 mm LAMS placement under endosonographic and fluoroscopic guidance. She returned in 2 weeks for subsequent ERCP through dual transluminal connection consisted of gastrogastrostomy and duodenal LAMS. The duodenoscope was advanced through gastrogastrostomy and duodenal LAMS to the major papilla without difficulty. Biliary sphincterotomy and plastic biliary stent placement were performed. A large amount of sludge and stone was extracted. She was discharged the same day with improvement in symptoms. All stents were removed 6 weeks after the ERCP without complications. DISCUSSION: With application of LAMS, we described a novel case of EDGE procedure in patient with RYGB anatomy in conjunction with benign enteric stricture, which was performed through dual transluminal conduit comprised of gastrogastrostomy and duodenal LAMS. Other biliary access options were also considered. However, given the high likelihood of extensive adhesions from prior abdominal surgery, LA-ERCP posed a higher risk of complications, and balloon-assisted enteroscopy ERCP (BA-ERCP) has limited maneuverability which often leads to suboptimal success rates. This highly effective approach should be considered for situations where BA-ERCP is technically challenging, and when LA-ERCP is not feasible.