Su1425 IMPACT OF EUS GUIDED GASTRO-GASTROSTOMY TO FACILITATE FURTHER ENDOSCOPIC INTERVENTIONS IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS: MORE THAN JUST EDGE!

Abstract

The altered anatomy after Roux-en-Y gastric bypass (RYGB) restricts endoscopic access and prevents routine intervention to the excluded stomach, duodenum and pancreatico-biliary tract. EUS guided gastro-gastrostomy (EGGG) using a lumen-apposing mental stent (LAMS) has recently been reported to allow successful EUS-directed transgastric ERCP (EDGE). The potential interventions via EGGG, however, can be broader. The aim of this study is to evaluate the indication, safety, and clinical success of EGGG interventions in the upper GI tract. A prospectively collected database of RYGB patients referred for evaluation and treatment of suspected luminal or extraluminal pathology, in or around the duodenum and/or excluded stomach over a 15-month period was retrospectively reviewed. All patients underwent EGGG using an electrocautery enhanced LAMS delivery system (“Hot” Axios, Boston Scientific), followed by required interventions as indicated. After the relevant intervention, the LAMS was removed and the fistula was closed at the discretion of the endoscopists. The median follow-up was 6.3±1.9 months. 17 consecutive RYGB patients (66.9±3.4years; 16F:1M) underwent EGGG to facilitate endoscopic evaluation and/or intervention for suspected biliary stone on imaging (n=9), suspected biliary stricture with jaundice (n=3), bile leak (n=1), pancreatic mass (n=2), and need for PEG insertion (n=2). Technical and clinical success rates of EGGG were 100%. There were no complications. Mean procedure time was 40±5 minutes. All patients had a 20 mm diameter LAMS except one treated with a 15 mm due to unavailability of a 20 mm. The required interventions were performed during the same session in 7 (41%) patients, and were delayed in the remaining for a mean of 3.4±0.3 weeks. The post-EGGG interventions included EUS +/- fine needle aspiration (n=14), therapeutic ERCP (n=11), and PEG insertion (n=2). EUS evaluation after EGGG altered the management in 5/14 (35%): EUS-guided FNA confirmed carcinoma (n=2) and chronic pancreatitis (n=1), and EUS avoided unnecessary ERCP after excluding choledocholithiasis (n=2). All endoscopic interventions (stone extraction=9, biliary stent=4; FNA/FNB=3, PEG insertion=2) were successful without complications. The LAMS was removed at the time of intervention in 13/16 (81%) patients. Three (23%) received immediate fistula closure with over-the-scope clips. No weight gain was reported after EGGG except for the 2 patients with PEG feeding. The median number of procedures for EGGG was 2, and the mean duration for the second intervention was 32±3 minutes. In RYGB patients, EGGG via LAMS provided a safe, effective and reversible approach for endoscopic evaluation and intervention in the upper GI and pancreatico-biliary tracts.