EUS-directed Transgastric ERCP Research Articles

Su1317 “AHHH, THIS INTERVAL IS JUST RIGHT!” THE STORY OF EDGE AND THE THREE INTERVALS. CAN A SHORTENED (SEVERAL DAY) INTERVAL BETWEEN EUS-GASTROGASTROSTOMY AND TRANSGASTRIC ERCP MITIGATE THE RISK OF STENT (LAMS) DISLODGMENT WHILE FACILITATING A TIMELY ERCP?

EUS-directed transgastric ERCP (EDGE) is the newest endoscopic modality for treating pancreaticobiliary disorders in the setting of Roux-en-Y gastric bypass (RYGB). EDGE consists of EUS-directed gastrogastrostomy (GG) / jejunogastrostomy (JG) creation (step 1), followed by transgastric ERCP (step 2). These 2 procedural steps can be performed concomitantly (same session) or separately (different sessions). Single-session EDGE (EUS-GG and transgastric ERCP during index procedure) is immediately therapeutic but risks perforation via stent (LAMS) dislodgment. Dual-session EDGE (transgastric ERCP performed after GG fistula maturation) does not risk perforation, but the clinical malady festers during the 2-3 week interval required for fistula maturation. We propose a “shortened-interval dual-session” EDGE (2 – 4 day interval) to balance this dilemma. Our study compares 20-mm LAMS dislodgment risk between single-session and shortened-interval dual-session EDGE. We conducted a single-center retrospective study of 19 RYGB patients who underwent EDGE using 20-mm by one advanced endoscopist between 3/2018 – 9/2019. Given the small sample size, a permutation of regressor residuals test was conducted to investigate the association between EDGE interval type and LAMS dislodgment, controlling the effect of fistula type. All statistical analyses were performed on R (Version 3.6.1). Ten patients (5 ♀; mean 54 years) underwent single-session EDGE via GG (n = 6) or JG (n = 4) (Table 1). LAMS dislodgment occurred in 5 cases (50%), followed by successful intra-procedural rescue with a bridging esophageal FCSEMS. One adverse event (moderate severity) and 1 technical failure (10%) occurred in the same patient because transgastric ERCP was aborted and postponed after the rescue maneuver. Nine patients (7 ♀; mean 60 years) underwent a shortened-interval dual-session EDGE via GG (n = 5) or JG (n = 4). The median interval between EUS-GG and transgastric ERCP was 3-days (range 2-4). LAMS dislodgment occurred in 1 case (11%), followed by successful rescue with a bridging FCSEMS. Technical success was 100% and no adverse events occurred in this group. The permutation test showed that the odds of LAMS dislodgment using single-session EDGE was 841% that of using shortened-interval dual-session EDGE (OR 8.41), after controlling for the effect of fistula type (Table 2). There was significantly greater odds of stent (20-mm LAMS) dislodgment during single-session EDGE compared to shortened-interval dual-session EDGE, after controlling for the effect of fistula. We hypothesize that a shortened interval dual-session EDGE may decrease the risk of LAMS dislodgment by allowing for mucosal anchoring and complete expansion of the LAMS, prior to transgastric ERCP.

Su1258 “INNOCENT AS A LAMS.” DOES SPONTANEOUS GASTROGASTRIC/JEJUNOGASTRIC FISTULA CLOSURE (HEALING BY SECONDARY INTENTION), AFTER EUS-DIRECTED TRANSGASTRIC ERCP (EDGE) VIA 20-MM LAMS, CONFER AN INCREASED RISK OF PERSISTENT FISTULA AND UNINTENTIONAL WEIGHT GAIN?

EUS-directed transgastric ERCP (EDGE) is an effective modality for treating pancreaticobiliary disorders in Roux-en-Y gastric bypass (RYGB) anatomy. EDGE is a 2-in-1 procedure that consists of EUS-directed gastrogastrostomy (or jejunogastrostomy) creation using a lumen-apposing metal stent (LAMS), followed by, transgastric ERCP. After completion of transgastric ERCP and maturation of the gastogastric fistula (GGF) or jejunogastric fistula (JGF), the LAMS is removed with the intention of re-excluding the bypassed stomach. Closure of the GGF/JGF can occur via primary intent (endoscopic closure) or secondary intent (spontaneous closure). Persistent fistula is a concerning sequela of EDGE, as it may functionally reverse the bypass. Prior EDGE studies, using 15-mm LAMS, report persistent fistula rates of 4 – 20%, without a clear association with weight gain. Our study measures the incidence of persistent fistula and its association with unintentional weight gain, among patients whose fistula was allowed to spontaneously heal, after EDGE using 20-mm LAMS. We conducted a single-center retrospective study of 16 RYGB patients who underwent EDGE using 20-mm by one advanced endoscopist between 3/2018 – 9/2019. After LAMS extraction, all GGFs/JGFs were allowed to heal spontaneously. Objective testing for persistent fistula occurred 5-months (median) after LAMS extraction, using upper gastrointestinal series or EGD. A GGF/JGF was considered “persistent” if detected at least 2-months after LAMS extraction. Change in total body weight (TBW) was calculated relative to pre-EDGE (baseline) TBW. All statistical analyses were performed on R (Version 3.6.1). Persistent fistula was identified in 50% of patients (n = 8) (Table 1). A longer LAMS dwell time (median 89-days) was observed in the persistent fistula group, compared to those without persistent fistula (median 34-days) (p = 0.0499). Weight gain of > 5% TBW occurred in 50% (n = 4) of patients with persistent fistula, compared to 25% (n = 2) of patients without persistent fistulas (p = 0.6084). A 50% persistent fistula rate is the highest reported incidence to date (compared to studies using 15-mm LAMS). We hypothesize that 20-mm LAMS leaves a wider transmural defect than 15-mm LAMS, and that healing by secondary intent may be slower than by primary intent. Persistent fistula was significantly associated with a longer LAMS dwell time, possibly due to more permanent tissue remodeling around the LAMS. Weight gain was not significantly associated with persistent fistula; thus, we question the utility of routine fistula closure (by primary intent) and suggest a personalized approach to follow-up. Multicenter collaboration is needed to better understand the natural history and optimal management of persistent fistula occurring after EDGE.

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

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.

Gastric overtube use to prevent duodenoscope loop formation during EUS-directed transgastric ERCP procedure.

A patient with a history of Roux-en-Y gastric bypass surgery in 2003 and cholecystectomy in 2017 was transferred for evaluation of biliary-type abdominal pain and abnormal liver test results. Abdominal US scan demonstrated a dilated bile duct measuring 1.4 cm and choledocholithiasis (Fig. 1). Upper endoscopy confirmed normal Roux-en-Y anatomy, and an EUS-directed transgastric ERCP procedure was planned.

Management of adverse events of EUS-directed transgastric ERCPprocedure.

Background and AimsAccessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period.MethodsThis was a retrospective review of 4 patients with RYGB anatomy who underwent EDGE for the management of pancreaticobiliary disease and experienced LAMS-related adverse events. Techniques for managing and avoiding these events are discussed.ResultsFour patients underwent EDGE with both technical and clinical success. Slight LAMS migration with partial mucosal overgrowth was encountered in 1 case and was managed by LAMS removal. A large, bleeding, distal marginal ulcer after the EDGE procedure was encountered in the second case and was managed with proton pump inhibitor and removal of the LAMS, with fistula treatment with argon plasma coagulation used to enhance closure. The third case was complicated by moderate intraprocedural bleeding after LAMS dilation, which was managed by applying balloon tamponade and placing a through-the-scope esophageal stent across the LAMS. Last, preferential food passage to the excluded stomach was noted in the fourth case and resulted in symptomatic distention. The symptomatic distention was managed by another de novo jejunogastrostomy using a LAMS for drainage.ConclusionsDespite its feasibility and acceptable safety profile, the use of LAMSs during EDGE could be associated with several procedure-specific adverse events, which can be avoided or managed endoscopically with no further consequence.

917 EUS-Directed Transgastric ERCP (EDGE) versus Laparoscopy-Assisted ERCP (LAERCP) for Roux-en-Y Gastric Bypass (RYGB): A Single Center Experience

INTRODUCTION: The rising obesity epidemic in the US has led to an increase in bariatric surgeries, and Roux-en-Y gastric bypass (RYGB) is a common option. These patients are at higher risk for gallstone disease, but the resulting altered anatomy presents unique challenges to accessing the bile duct. Lap-assisted ERCP (LAERCP) is the most common modality for biliary access in this setting but leads to high resource utilization and morbidity. EUS-directed trans-gastric ERCP (EDGE), is emerging as a new alternative. We present a comparison between the performances of LAERCP and EDGE in RYGB patients at our institution. METHODS: The protocol was approved by the institutional review board. Charts were reviewed for all RYGB cases that underwent LAERCP or EDGE at our health system between 5/2009 – 5/2019. Patient demographics, procedural and clinical information was gathered. Both groups were compared using students T test for continuous variables and Pearson’s chi square and Fisher exact test for categorical variables. RESULTS: A total of 76 RYGB patients (17 EDGE and 59 LAERCP) were analyzed. The mean age, gender and indication for the procedure (biliary vs pancreatic) were similar in both groups. All EDGE and LAERCP were performed in a single step setting. Technical success of obtaining access to the excluded stomach was 100% for both groups. There was no statistical difference in the technical success of therapeutic ERCP between the two groups (94% EDGE vs 100% LAERCP). There was no difference in the adverse event rates between EDGE (6%) and LAERCP (17%). The EDGE group had significantly shorter procedural time as compared to LAERCP (103 vs 208 min, P < 0.001); but there was no difference in the length of hospital stay (2.7 vs 2.6 days, P = 0.94). The median time for lumen-apposing metal stent removal was 22 days (range 0-111). There was no significant weight gain (-6.33 lbs) at median follow up of 35 days in the EDGE group. CONCLUSION: Overall success rate of intended therapeutic intervention and adverse event profile are similar for EDGE and LAERCP. EDGE has significantly shorter procedure time and can be done independently in the endoscopy unit, unlike LAERCP which requires operating room availability and coordination with a skilled laparoscopic surgeon. EDGE can be considered as a safe and effective first line modality for pancreaticobiliary access in RYGB patients offering the benefit of repeat ampullary access if needed on follow up procedure and without any worries of significant weight gain.

921 Efficacy and Safety of Endoscopic Ultrasound-Directed Transgastric ERCP in Gastric Bypass Patients: A Systematic Review and Meta-Analysis

INTRODUCTION: Treating pancreaticobiliary disorders in Roux-En-Y gastric bypass patients poses a technical challenge for physicians. The traditional laparoscopic or device assisted enteroscopic techniques has high post procedural complications and failure rates. EUS directed transgastric ERCP (EDGE), which accesses the ampulla by creating a temporary fistula through the remnant stomach for standard ERCP, has shown promising results. We conducted a systematic review and meta-analysis to evaluate and compare the efficacy and safety of EDGE. METHODS: MEDLINE, EMBASE, and SCOPUS databases were utilized to search for eligible studies that reported on efficacy and safety from 2012-2019. Efficacy was defined as the ability to create a temporary fistula through a lumen apposing metal stent (LAMS) and conduct an ERCP. Safety included assessing adverse events. The studies included were retrospective studies and were assessed with the NHBLI tool. Figure 1 depicts the flow chart used for study screening. RESULTS: A total of 4 studies (n = 88 patients) were included in the analysis. The mean age of patients undergoing EDGE was 56 years with 86% females. All patients evaluated were status post roux-en-y gastric bypass and the most common indication for the procedure was choledocholithiasis. Pooled technical success was 98.8% (95% CI 0.96-1.0) although 13 cases involved either LAMS misdeployment or LAMS migration during ERCP requiring rescue or repositioning. A total of 8 adverse events (8% 95% CI 0.03-0.16) occurred including intra-procedural bleeding, pancreatitis, persistent fistula formation or perforation. Figures 2,3 highlight the clinical success and adverse events of the EDGE technique. CONCLUSION: EUS directed transgastric ERCP (EDGE) appears to be an effective and safe procedure for Roux-EN-Y gastric bypass patients to undergo ERCP. Further studies are needed to address optimal procedural techniques, including access tract closure and to assess long term adverse events such as post procedural weight gain.

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

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.

The EDGI new take on EDGE: EUS-directed transgastric intervention (EDGI), other than ERCP, for Roux-en-Y gastric bypass anatomy: a multicenter study.

Background and study aims Indications for accessing the duodenum, and/or excluded stomach in Roux-en-Y gastric bypass (RYGB) patients extend beyond diagnosis and treatment of pancreaticobiliary maladies. Given the high technical and clinical success of EUS-directed transgastric ERCP (EDGE) in RYGB anatomy, we adopted this transgastric (anterograde) approach to evaluate and treat luminal and extraluminal pathology in and around the excluded gut in RYGB patients. EUS-directed transgastric intervention (“EDGI”), other than ERCP, is the terminology we have chosen to describe this heterogenous group of transgastric diagnostic and/or interventional endoscopic procedures (transgastric interventions) performed via a lumen-apposing mental stent (LAMS) in select patients with RYGB. Patients and methods A multicenter (n = 4), retrospective study of RYGB patients with suspected luminal or extraluminal pathology, in or around the duodenum and/or excluded stomach, underwent EDGI using LAMS between December 2015 and January 2019. Results A total of 14 patients (78.6 % women; mean age, 55.7 + 12.4 years) underwent EDGI via LAMS. Technical and clinical success rates of EDGI were 100 %. The most common transgastric interventions were diagnostic EUS of extraluminal pathology (n = 6, 42.7 %) and endoscopic biopsy of gastroduodenal luminal abnormalities (n = 5, 35.7 %). Two moderate-severity adverse events due to LAMS maldeployment occurred during EUS-JG creation (14.3 %), and each instance was successfully rescued with a bridging stent. Conclusions A variety of gastroduodenal luminal and extraluminal disorders in RYGB patients can be effectively diagnosed and managed using EDGI via LAMS.

2185 69-Year-Old Male After Gastric Bypass With Choledocholithiasis Treated With EDGE Procedure Complicated by LAMS Dislocation

INTRODUCTION: With the alarming increase in the prevalence of obesity, more people are undergoing bariatric surgeries of which most common is Roux-en-Y gastric bypass (RYGB). This altered anatomy poses challenges in accessing the papilla for ERCP in the setting of biliary pathology. Until recently enteroscopy or surgery assisted ERCP were the two main treatment options. Today, EUS-directed trans-gastric ERCP (EDGE) procedures have emerged as a promising treatment option in such circumstances. CASE DESCRIPTION/METHODS: A 69-year-old male with history of RYGB, cholecystectomy, Barret’s esophagus, CAD and CKD was admitted with one day history of vomiting and RUQ abdominal pain. On initial evaluation the patient was afebrile, normotensive with scleral icterus. Labs were significant for leukocytosis (14.2 10^3/µL), elevated transaminases (AST 254 U/L; ALT 231 U/L) and signs of biliary obstruction (ALP 252 U/L; bilirubin 3.3 mg/dl). Abdominal imaging (CT, US) revealed dilated intra and extra hepatic biliary ducts with the CBD measuring 1.4cm. For further evaluation, an EDGE procedure was performed within 24 hours. After injecting water to form a fluid collection in the stomach and confirming no blood flow in the path, a 20mm Hot Axios LAMS was successfully deployed under EUS guidance. The gastric lumen was confirmed after dilatation to 18mm. The duodenoscope was advanced and subsequent cholangiogram revealed several large stone filling defects along with dilated hepatic ducts. A sphincterotomy was performed, 9-12mm followed by 12-15mm extraction balloons were advanced over the wire and after multiple sweeps, 5 large stones were removed with resolution of biliary obstruction. During the ERCP, the LAMS dislodged into the native stomach over the scope but was able to be successfully removed by rat-tooth forceps. Finally, the fistula was closed using endo-clips and the patient reported resolution of his symptoms and LFTs normalized. DISCUSSION: Choledocholithiasis after RYGB is not unusual as nearly 50% of patients develop biliary stones within two years after surgery. The most common complications after EDGE procedure are bleeding from the fistula site, persistent fistula formation, perforation or adverse events related to ERCP. We present a rare case of LAMS dislocation into the stomach during EDGE which was successfully removed with the snare. Being able to recognize and immediately treat this potential complication may help providers anticipate it during EDGE procedures.

Endoscopic abdominal exploration in the acute abdomen: No longer a contraindication?

A 41-year-old man with a history of Roux-en-Y gastric bypass, decompensated nonalcoholic steatohepatitis cirrhosis, ascites, and recurrent acute pancreatitis presented to the emergency department with an acute abdomen. Six months prior, he underwent the first stage of an EUS-directed transgastric ERCP (EDGE) procedure, wherein a 15-mm lumen-apposing metal stent (LAMS) was placed between the pouch and the remnant stomach, because of a pancreatic duct leak complicated by a 10-cm peripancreatic fluid collection. Given that his pancreatic duct leak and fluid collection spontaneously resolved on follow-up imaging with normal lipase as shown by follow-up paracentesis, the LAMS was removed 2 months later.

An adverse event of EUS-directed transgastric ERCP: stent-in-stent technique to bridge the peritoneal gap.

An adverse event of EUS-directed transgastric ERCP: stent-in-stent technique to bridge the peritoneal gap.

907 SIMPLE FIX OF JEJUNO-JEJUNAL LAMS DISLODGMENT DURING POST-BARIATRIC THROUGH-THE-STENT ERCP

EUS directed trans-Gastric ERCP (EDGE) allows access to the excluded stomach in Roux-en-Y gastric bypass (RYGB) patients by means of gastro-gastrostomy or jejuno-gastrostomy. We similarly fashioned a jejuno-jejunal EUS-guided lumen-apposing metal stent (LAMS) anastomosis to allow through-the-stent (TTS) ERCP in a patient with recurrent pancreatitis and duodenal switch (DS), a type of bariatrically altered anatomy distinctly precluding peroral ERCP. Endoscopic techniques for localizing the biliary limb in DS and for salvaging LAMS dislodgment are presented.

Su1167 EUS-DIRECTED TRANSGASTRIC ERCP WITH 20 MM LUMEN-APPOSING METAL STENTS IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS, ARE WE CLOSER TO PERFECTION?

Pancreaticobiliary access in patients with Roux-en-Y gastric bypass (RYGB) poses a significant challenge for therapeutic endoscopists. With the advent of lumen-apposing metal stents (LAMS), EUS-directed transgastric ERCP (EDGE) procedures have gained popularity as a favorable alternative to laparoscopy and enteroscopy assisted ERCP. Thus far, there have widely varied intervals between steps and adverse event rates reported. In addition, there have been few reports with use of 20 mm LAMS, hence it’s procedural and peri-procedural impact remains unknown.

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

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.

Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP.

Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP.

EUS-directed transgastric ERCP (EDGE) with use of a20-mm×10-mm lumen-apposing metal stent in apatientwithRoux-en-Y gastric bypass.

EUS-directed transgastric ERCP (EDGE) with use of a20-mm×10-mm lumen-apposing metal stent in apatientwithRoux-en-Y gastric bypass.

Spiral enteroscopy–assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video)

Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (asingle-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.

Closure of an iatrogenic gastrogastric fistula created during EUS-directed transgastric ERCP.

Closure of an iatrogenic gastrogastric fistula created during EUS-directed transgastric ERCP.

EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach

ERCP is challenging in patients with Roux-en-Y gastric bypass. Using EUS to gain access to the excluded stomach and subsequently performing transcutaneous ERCP was described recently. We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). Single-center case series. Tertiary center with expertise in EUS-guided procedures. Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. A linear echoendoscope was used to access the excluded stomach. A LAMS was deployed over a wire to create a gastrogastric or jejunogastric fistula. A duodenoscope was then passed through the LAMS and conventional ERCP was performed. Technical and clinical success rates as well as adverse events. EUS-guided creation of a gastrogastric or jejunogastric fistula via placement of a LAMS was successful in all cases (100%). The ability to perform ERCP through the fashioned fistula during the index procedure was successful in 3 of 5 cases (60%). Two LAMS dislodgments requiring restenting were observed. No major adverse events were observed. No weight regain occurred. The median procedure time was 68.0 minutes. Small sample, single-institution experience. The internal EDGE procedure may offer a cost-effective, minimally invasive option for a common problem in a growing patient demographic. Further refinement of the technique is required to minimize adverse events. ( NCT01522573.).