Gastric Bypass Anatomy Research Articles

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

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.

Author commentary on Jagpal Singh Klair et al.

Jagpal Singh Klair et al. ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis

A comparison of clinical outcomes and cost utility among laparoscopy, enteroscopy, and temporary gastric access-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy

Gastric Access Temporary for Endoscopy (GATE), also known as EUS-Directed Trangastric ERCP (EDGE), has demonstrated advantages over device-assisted enteroscopy (DAE) and laparoscopic-assisted ERCP (LA-ERCP) for patients with Roux-en-Y gastric bypass (RYGB) anatomy. We aimed to directly compare clinical outcomes and cost utility among the three ERCP modalities. Patients with RYGB anatomy who had DAE, LA-ERCP, or GATE from 2009 to 2019 at 2 tertiary centers were included in our review. We measured outcomes in three areas: success rate, post-procedural adverse events (AEs) and hospitalization, and cost utility per Medicare/Medicaid insurance payments. Cohort Total 130 patients (70 underwent DAE, 42 LA-ERCP, and 18 GATE). Success rate DAE was successful in 59% of patients, compared to success rates of 98 and 100% for LA-ERCP and GATE, respectively (p < 0.001). For DAE, 62% of unsuccessful cases required rescue therapy. Adverse events and hospitalization Patients who underwent GATE had the lowest rate of hospitalization post procedure (44% vs. 77% and 100% for DAE and LA-ERCP, respectively, p < 0.01) and spent the least amount of time hospitalized (median time 0days vs 2 and 3days for DAE and LA-ERCP, respectively, p < 0.0001). GATE had lower AE rates than LA-ERCP (6 vs 31%, p = 0.046), and both had similar rates to DAE. Cost utility LA-ERCP carried the highest total procedural and hospitalization cost per Medicare/ Medicaid insurance payments (median payment difference of $9.7K vs GATE and $7.9K vs DAE, p < 0.01 for both). Procedural and hospitalization costs were similar between GATE and DAE (p = 0.76). GATE is a safe modality for ERCP with high success rates in RYGB patients and exhibits the lowest hospitalization time and rate of adverse events when compared to DAE and LA-ERCP. GATE is similar to DAE from a cost utility approach, and both are less costly than LA-ERCP.

Temporary Trans-gastric Stent Deployment Over a 20 French Gastrostomy for Single-Stage Endoscopic Retrograde Cholangiopancreatography After Gastric Bypass.

Treatment of pancreato-biliary disorders after gastric bypass is challenging due to altered anatomy. Several techniques have been proposed to overcome this condition; however, none has emerged as the gold standard treatment. Furthermore, a decision-making algorithm evaluating when and why apply one technique over another is still lacking. To describe a novel trans-gastric approach to allow endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass (RYGB) anatomy soon after prior laparoscopic cholecystectomy (LC) and to propose a decision-making algorithm for selection of the most suitable technique according a tailored approach. Private hospital. Between January and March 2020, patients with Roux-en-Y gastric bypass anatomy referred to our tertiary center to undergo ERCP after recent laparoscopic cholecystectomy were retrospectively evaluated. A 20 french (Fr) gastrostomy was performed during cholecystectomy. A single-stage ERCP was carried out by means of temporary trans-gastric stent deployment over a 20 Fr gastrostomy. A total of 5 patients (mean age 41; mean body mass index 48.3) were enrolled. ERCP was performed after an average of 2days from surgery. Technical and clinical success was achieved in 100%. No adverse events occurred. Spontaneous closure of the gastrostomy after its bedside removal was observed in all cases. Our approach allows to perform a single-stage ERCP in RYGB patients, early after LC, with no need of any other re-interventions. Any surgeon facing unexpected biliary disorders, during LC, can easily perform a 20 Fr gastrostomy thus allowing the patient to undergo early ERCP without any delay.

Endoscopic management of symptomatic walled-off omental fat necrosis.

Endoscopic management of symptomatic walled-off omental fat necrosis.

ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events. We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone. 10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted. OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.

1066 A START OF A NEW TREND: TRANS-REMNANT ENDOSCOPIC DRAINAGE FOR MANAGEMENT OF WALLED-OFF NECROSIS IN A PATIENT WITH ROUX-EN-Y GASTRIC BYPASS

A 64-year old female with a history of Roux-en-y gastric bypass was admitted to our hospital for management of severe pancreatitis complicated by walled-off necrosis. In this patient, large areas of walled-off necrosis extended along the pericolic gutters and were not in close communication with the gastric pouch. Thus, we performed a trans-remnant endoscopic drainage (TREnD) procedure. The excluded stomach was accessed via a lumen apposing metal stent which was then dilated and sutured into place. Later, once the excluded stomach was accessed, additional transgastric and transduodenal lumen apposing metal stents were deployed and necrosectomies were performed. Following our multiple interventions with lumen apposing metal stents resolution of the patient’s fluid collections was achieved. Our case illustrates how the TREnD procedures allows endoscopists to manage complex fluid collections in patients with Roux-en-y gastric bypass anatomy.

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.

Tu1114 HIGH LEVEL DISINFECTION DUODENOSCOPE PROCESSING MIGHT BE ASSOCIATED WITH HIGHER RATE OF INFECTIOUS COMPLICATION FOLLOWING LAPAROSCOPY ASSISTED ERCP, A MULTICENTER STUDY

Laparoscopy-assisted (LA) ERCP is highly successful procedure in patients with roux-en-y gastric bypass (RYGB) anatomy. Yet, it carries a significant change to the usual gastroenterology practice as the scope is entering through a sterile, surgically made orifice. This poses the question of the need for Ethylene Oxide (ETO) gas sterilization for duodenoscope reprocessing as compared the standard high-level disinfection (HLD) that is commonly used for regular ERCP. Our aim was to evaluate the rate of infectious complication following LA-ERCP according to the scope reprocessing method. This is an IRB approved, retrospective study that included adult patients with RYGB undergoing LA-ERCP in 25 centers in the United States, 1 in Canada, and 1 in Brazil. A standardized data entry form was distributed across all the centers to collect information about demographics, indications, operative details, success rate, scope reprocessing method, and complications. Rates of infectious complications were compared according to duodenoscope reprocessing method using Fisher's Exact Test. We included 457 patients with median age of 52 (+/- 12) years and 86% females. Indication for lap-assist ERCP was biliary in 92% (stones 50%) and pancreatic in 8% (acute pancreatitis 94%). Success in reaching the papilla was achieved in 99%, cannulating the desired duct in 99%, and performing the desired intervention in 98%. Scope processing was with HDL and periodic cultures in 381 cases (83%) whereas it was with ETO gas sterilization (proceeded by HDL) in 76 cases (17%). Overall rate of infectious complication was 6.9%. Port site or surgical wound infections reported 3.7%. Whereas post ERCP cholangitis reported in 1.3% of the cases. There was a trend towards less infectious complications among ETO gas sterilization cases with a rate of overall infectious complication of 3.9% versus 7.5% (p=0.196), site or surgical wound infections 2.6% versus 3.9% (p=0.671) as compared to HLD cases. On the other hand, there was significantly less perioperative antibiotics used with ETO gas sterilization as compared to HLD cases (75% versus 90%, p <0.001) group, Table 1. Our large multicenter study indicates that ETO gas sterilization might be associated with less infectious complication following LA-ERCP as compared to HLD. Lack of statistical significance is attributed to low power due to the rarity of the infectious outcomes. However, ETO gas sterilization was associated with statistically significant less use of peri-procedure prophylactic antibiotics and yet showed a clinically relevant trend toward lower infectious rates. Although the optimal duodenoscope processing prior to LA-ERCP remains to be determined, it appears sensible to perfume ETO gas sterilization and administer pre-procedure antibiotic prophylaxis to lower the chance of infectious complications.

Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy, which is increasing in frequency given the rise of obesity. Laparoscopy-assisted ERCP (LA-ERCP) and enteroscopy-assisted ERCP (EA-ERCP) are distinct approaches with their respective strengths and weaknesses. We conducted a meta-analysis comparing the procedural time, rates of success and adverse events of each method. Patients and methods A search of PubMed, EMBASE and the Cochrane library was performed from inception to October 2018 for studies reporting outcomes of LA or EA-ERCP in patients with RYGB anatomy. Studies using single, double, ‘short’ double-balloon or spiral enteroscopy were included in the EA-ERCP arm. Outcomes of interest included procedural time, papilla identification, papilla cannulation, therapeutic success and adverse events. Therapeutic success was defined as successful completion of the originally intended diagnostic or therapeutic indication for ERCP. Results A total of 3859 studies were initially identified using our search strategy, of which 26 studies met the inclusion criteria. The pooled rate of therapeutic success was significantly higher in LA-ERCP (97.9 %; 95 % CI: 96.7–98.7 %) with little heterogeneity (I 2 = 0.0 %) when compared to EA-ERCP (73.2 %; 95 % CI: 62.5–82.6 %) with significant heterogeneity (I 2 : 80.2 %). Conversely, the pooled rate of adverse events was significantly higher in LA-ERCP (19.0 %; 95 % CI: 12.6–26.4 %) when compared to EA-ERCP (6.5 %; 95% CI: 3.9–9.6 %). The pooled mean procedure time for LA-ERCP was 158.4 minutes (SD ± 20) which was also higher than the mean pooled procedure time for EA-ERCP at 100.5 minutes (SD ± 19.2). Conclusions LA-ERCP is significantly more effective than EA-ERCP in patients with RYGB but is associated with a higher rate of adverse events and longer procedural time.

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.

Overall outcomes of laparoscopic-assisted ERCP after Roux-en-Y gastric bypass and sphincter of Oddi dysfunction subgroup analysis.

Background and study aims Biliary access following Roux-en-Y gastric bypass (RYGB) anatomy presents a significant challenge. Long-term outcomes of laparoscopic-assisted trans-gastric ERCP (LA-ERCP) including sphincter of Oddi dysfunction (SOD) subtypes have not been thoroughly examined. Our study aims to present our overall outcomes of trans-gastric LAERCP and examine a significant subgroup of patients with SOD after RYGB. Patients and methods A retrospective review of RYGB patients who underwent LA-ERCP between 2009 and 2016 identified 51 patients. A subgroup of 22 patients with SOD were examined and contacted by phone survey to determine long-term symptom resolution. Results Post-procedure length of stay was 1.9 days (SD 3.0). There was one conversion from laparoscopic to open procedure. Selective cannulation rate was 100 %. Mean follow-up was 14.6 months. There were two major operative complications, two major ERCP-related complications, and five wound infections (9.8 %). No deaths or episodes of pancreatitis occurred. Seventeen patients had biliary SOD (Type I = 9, Type II = 8). The remaining four had pancreatic SOD (Type I = 1, Type II = 4). SOD subgroup follow-up was 21.4 months (SD 18.1). All patients with Type I biliary and 75 % with Type I pancreatic SOD reported complete resolution of their symptoms. Conclusions Consistent with other published series, LA-ERCP yields excellent cannulation rates after RYGB. Successful treatment of pancreatic and Type 1 biliary SOD suggests that there is significant symptomatic benefit to treating this patient population. However, an overall complication rate of approximately 15 % with LAERCP leaves open the possibility for improvements in access techniques in post-RYGB patients.

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.

Sa1469 ERCP WITH OVERTUBE-ASSISTED ENTEROSCOPY IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS ANATOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Unlike other post-surgical altered anatomies like Whipple surgery, Billroth II or Roux-en-Y hepatico-jejunostomy, overtube assisted enteroscopy (OAE) is usually needed to perform ERCP in RYGB anatomy as the combined length of Roux limb and biliopancreatic limb needs to be traversed to access the papilla. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to estimate the pooled rate of success and adverse events.

Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients.

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is technically challenging. Device-assisted enteroscopy and laparoscopic-assisted methods suffer from high failure rates and/or post-procedural complications. A novel endoscopic technique termed EUS-Directed Transgastric ERCP (EDGE) or Gastric Access Temporary for Endoscopy (GATE) has recently emerged, demonstrating excellent technical and therapeutic success. The technique involves endoscopic ultrasound-guided deployment of a lumen-apposing metal stent (LAMS) to gain access into the remnant stomach to facilitate standard ERCP. In this case series, we describe our center's experience and unique approach with the GATE procedure and discuss several key strategies and differences. Patients underwent the GATE procedure via a novel algorithmic approach. Key information on procedural details, technical and clinical success, follow-up, and adverse events was prospectively collected and retrospectively reviewed. 10 patients underwent the GATE procedure from May 2017 to March 2018. Technical and clinical success were both 100%. Gastric and jejunal access points for LAMS deployment were 30% and 70%, respectively. Total procedure time per patient, including LAMS deployment, ERCP, and all follow-up procedures, averaged 2.37 ± 0.63h. 2 out of 10 patients (20%) had adverse events that were resolved either intra-procedurally or after repeat endoscopy with no long-term complications and none requiring surgery. For patients with complete follow-up (n = 7), access tract closure rate was 100% with the aid of a temporary plastic double pigtail stent to facilitate closure. GATE appears to be a safe and effective procedure and may be considered the preferred approach to ERCP in patients with RYGB anatomy at centers with LAMS experience. The procedure offers more definitive and higher range of ERCP interventions compared to traditional methods and is associated with fewer adverse events. Improvements in strategies and methods with the GATE technique may reduce risks and improve outcomes.

Therapeutic EUS: New tools, new devices, new applications

Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.

EDGE Procedure to allow EUS/FNB of an uncinate process pancreatic mass in a patient with gastric-bypass anatomy using a 20-mm lumen-apposing metal stent.

EDGE Procedure to allow EUS/FNB of an uncinate process pancreatic mass in a patient with gastric-bypass anatomy using a 20-mm lumen-apposing metal stent.

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure

Endoscopic ultrasound-directed transgastric ERCP (EDGE) by creating an anastomosis from the gastric pouch or jejunum to the excluded stomach allows performance of ERCP in Roux-en-Y gastric bypass (RYGB) anatomy. Concern for persistent fistula following stent removal and sparse data limit adoption. Retrospective review of consecutive patients undergoing EDGE over a 2-year period. Nineteen RYGB patients underwent EDGE; three had previously failed ERCP by the device-assisted method. Indications for ERCP were choledocholithiasis (8), recurrent acute pancreatitis (6), benign post-surgical stricture (3), elevated bilirubin, and papillary stenosis (1 each). EDGE was technically successful in all 19 patients with jejunogastric anastomosis in 11 patients and gastrogastric in 8 using a 15-mm lumen-apposing metal stent. Stent malposition occurred in six and was managed by rescue maneuvers. ERCP was performed in the same session in four patients; the remainder were delayed after a mean of 48days. Diagnostic endoscopic ultrasound (EUS) was performed in four patients. No severe adverse events occurred; clinical success was 100%. Stents were removed after a mean dwell time of 182days. Argon plasma coagulation (APC) was used to promote fistula closure in 12 patients. Upper GI series to assess fistula closure was obtained in 11 patients after a mean of 182days following stent removal. One persistent fistula was identified and closed endoscopically. EDGE is an effective modality for performing ERCP in patients with RYGB anatomy and can be performed via gastrogastric or jejunogastric approaches. Persistent fistula is uncommon and can be managed endoscopically. APC may promote fistula closure.

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.

Peroral endoscopic myotomy for the treatment of achalasia patients with Roux-en-Y gastric bypass anatomy.

The outcome of peroral endoscopic myotomy (POEM) in patients with prior Roux-en-Y gastric bypass (RYGB) is not known and some experts have recommended against its performance in this patient population because of the risk of postoperative regurgitation. The aim of this study was to report on the outcomes of POEM in patients with RYGB anatomy. Patients with RYGB anatomy who underwent POEM for the treatment of achalasia at three tertiary centers were included. POEM was performed in standard fashion using the anterior or posterior approach. Clinical response was defined by a decrease in Eckardt score to ≤ 3. Results of esophageal acid exposure testing/pH-impedance and manometric testing after POEM were reported when available. A total of 10 achalasia patients with prior RYGB surgery underwent POEM. All procedures were technically successful with anterior myotomy performed in seven patients. The mean submucosal tunnel length and myotomy length were 12.9 cm and 11.1 cm, respectively. The mean procedure time was 72 minutes and mean length of hospital stay was 1.5 days. Clinical success was achieved in all 10 patients with a significant decrease in Eckardt score from 6.5 to 1 (P < 0.001). None of the patients experienced post-procedural regurgitation. Post-procedural pH testing was obtained in six patients and was normal in all of them. This study suggests the feasibility, safety, and efficacy of POEM in patients with prior RYGB surgery. The risk of gastroesophageal reflux disease in these patients seems to be minimal after POEM.