Transgastric ERCP Research Articles

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.

3163 Laparoscopic Transgastric ERCP for Choledocholithiasis After Roux-en-Y Gastric Bypass: A Different Approach to ERCP

INTRODUCTION: With bariatric procedures becoming more prevalent, performing an ERCP becomes a challenge with patients who have had bariatric surgeries. CASE DESCRIPTION/METHODS: A 60 year old male with a past medical history of hypertension, diabetes mellitus type 2, and Roux-en-Y gastric bypass surgery developed abdominal pain 3 days prior to admission and was admitted for a laparoscopic cholecystectomy. Pre-operative MRCP did not show any significant common bile duct obstruction (a small non-obstructing stone was noted). Intraoperatively, the stone was found to be obstructing the common bile duct after a cholangiogram was performed. A laparoscopic trans-gastric ERCP was scheduled. The ERCP was scheduled for the next day. After a laparoscopic gastrostomy, the ERCP scope was advanced through the gastrostomy and the stone was removed with standard biliary sphincterotomy and balloon extraction without complications. The gastrostomy site was closed, and the procedure finished without complications. The patient was discharged in good condition 2 days after the procedure. DISCUSSION: An ERCP in a Roux-en-Y gastric bypass patient requires careful planning with surgery. Nonetheless, the time of the procedure is shortened considerably compared to the older double-balloon approach and shorter anesthesia overall is associated with better outcomes for the patient. One surgical approach to these patients is a transgastric approach through gastrostomy (either laparoscopic or open surgical approach). The open approach is achieved by creating an opening in the abdominal wall, and attaching the gastric wall to the opening, then opening it for the ERCP scope to be advanced through. In this particular case, a laparoscopic gastrostomy was performed in the distal area of the stomach, and cannulated with a 15 mm cannula through an umbilical port. An 11 mm ERCP scope was then inserted through the trocar directly into the stomach, and advanced to the pylorus where the gastroenterologist was able to cannulate the common bile duct. A stent was not placed in this particular case, as it would require repeat surgery to remove it. The gastrostomy was then closed by a mini laparotomy. Alternative approaches to GI procedures will become more common with the growing prevalence of bariatric procedures.

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.

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.

919 Outcomes of Endoscopic Ultrasound Directed Trans-Gastric ERCP (EDGE): A Single Center Experience

INTRODUCTION: ERCP can be difficult in patients with Roux-En-Y foregut anatomy due to difficulty accessing the papilla, where balloon-assisted enteroscopy or laparoscopy based access has been used. Endoscopic ultrasound directed trans-gastric ERCP (EDGE) allows access to the excluded stomach via a lumen apposing metal stent (LAMS) from the gastric pouch, and passage of the duodenoscope in standard anatomical fashion. Early studies demonstrated high technical and clinical success rates of EDGE with few major adverse events (AEs). We aimed at describing rates of technical and clinical success and AEs of EDGE, impact on patients’ weight and incidence of persistent gastro-gastric fistulae (GGF). METHODS: This is a single center retrospective analysis of a prospectively collected database. All patients who underwent EDGE from 06/2018 to 05/2019 were included. AEs were defined per ASGE lexicon. Descriptive statistical analysis was used to assess outcomes. RESULTS: Nineteen patients were included in the study [mean age 59.4 years (SD = 10.7); 79% females, Table 1]. Two additional patients with spontaneous GGF noted at planned EDGE had no LAMS placed and were excluded. Choledocholithiasis was the most common indication (7/19, 37%), with three associated with cholangitis. Technical success for EUS guided LAMS placement/GGF creation was 100% (Hot AXIOS, 15 mm × 10 mm) with a mean procedure time of 26.8 (SD = 10) minutes and no major AEs. Same session ERCP was done in 2/19 (10%) with LAMS anchoring and 17/29 ERCPs (90%) performed a mean 5.5 (SD = 4.9) days after LAMS placement with a diagnostic duodenoscope (18/19, 95%) most commonly used. Mean ERCP time was 38.7 (SD = 4.9) min with a technical and clinical success of 95% (18/19). Two ERCP-related moderate adverse events occurred managed endoscopically and conservatively. LAMS were removed within 4 weeks of last ERCP, with APC +/- endoscopic suturing in 13/16 (81%) with 100% technical success of endoscopic closure. There was no weight gain noted on a mean follow up of 11.3(SD = 9) weeks. GGF resolution was confirmed in 5/16 with CT (1/5), Upper GI Series (2/5) or upper endoscopy (2/5) done in 6 months of GGF closure with other patients yet to reach the 6-month time-frame (Table 2). CONCLUSION: EDGE is an effective procedure for patients with Roux-en-Y foregut anatomy, with acceptable safety profile and low risk of persistent GGF or weight gain in this series. Further prospective studies are needed to assess the long-term safety, in regards to weight gain and persistence of GGF.

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.

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.

Laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography for management of choledocolithiasis after mini-gastric bypass surgery

Background Gallstones commonly form after bariatric surgery owing to rapid weight loss. Choledocolithiasis is one of the dangerous sequelae of gallstones. Mini-gastric bypass (MGBP) excludes the biliary tree from traditional evaluation and treatment with endoscopic retrograde cholangiopancreatography (ERCP). This prevents ERCP to be done through the normal route. Objective To assess the feasibility and outcome of laparoscopic-assisted transgastric ERCP in patients with choledocolithiasis after MGBP for extraction of common bile duct (CBD) stones. Patients and methods A retrospective study was conducted on 15 patients who had gallstones discovered in the CBD after MGBP in five bariatric centers. Overall, 750 participants (BMI >35 kg/m2) were observed after undergoing MGBP over 2 years, and 10 of them were included in the study after being diagnosed with primary CBD stones and presented with jaundice during a period of 2 years after surgery. All patients were hospitalized, and gallstones were extracted laparoscopically through a transgastric approach except for two patients. Results Of 15 patients, 11were managed laparoscopically, and gallstones were extracted successfully. Four patients were converted to open surgery, but the scope was still used in three of them to extract the stones, and the last one underwent open CBD exploration. Conclusion Laparoscopic-assisted transgastric ERCP is an effective and safe way of management of choledocholithiasis in post-MGBP patients.

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.

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.

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography: Preliminary experience and technique description.

Common bile duct lithiasis after Roux-en-Y gastric bypass (RYGB) or upper gastrointestinal stenosis has become a challenging problem nowadays, especially as obesity surgery is increasing. In this study, we assess the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) and describe its technique. A retrospective review of a prospectively collected database of consecutive patients undergoing a LAERCP between February 2014 and May 2015 was performed at a single institution. Indications were common bile duct lithiasis associated with acute or past episodes of cholangitis and pancreatitis. Endoscopic access to the gastric remnant was obtained laparoscopically. In total 5 cases were identified. Four of them had undergone a RYGB and one of them presented a benign esophageal peptic stenosis, not allowing peroral gastric access. Biliary cannulation using LAERCP associated with sphincterotomy and stone extraction was successfully achieved in all patients. Mean duration of the entire procedure was 134minutes (range: 66-200min). No early major complications were observed and the mean postoperative hospital stay was 4 days (range: 2-5 days). LAERCP is a safe and successful procedure for the treatment of common bile duct lithiasis when conventional biliary access is not feasible, notably after RYGB. Larger trials still need to be performed to evaluate efficacy, technical success, and complications related to this technique.

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.

EUS-specific stents: Available designs and probable lacunae.

Interventional EUS has seen exponential growth in its indications and applications in the last decade.[1,2,3] Dedicated endoscopic devices for EUS-guided interventions are still limited. Up until recently, the tools used have been borrowed from other procedures such as ERCP. In interventional EUS, the linear-array echoendoscope allows a needle to be advanced under EUS-guidance from the upper gastrointestinal lumen to the biliary, pancreatic, or another adjacent intestinal lumen. Real-time puncture can be performed and provide the possibility of EUS-guided transluminal drainage (EUS-TLD). Plastic stents and conventional self-expandable metallic stents (SEMSs) were initially used but present several limitations due to their design.[1,4,5] They lack lumen-to-lumen anchorage and present migratory risks in the absence of stricture to hold them in place. Plastic stents are associated with potential pneumoperitoneum and bile peritonitis, whereas fully-covered SEMS (FCSEMS), despite preventing bile leak, will not maintain secure apposition between two nonadherent organs. Furthermore, their length often exceeds the anatomical requirement of a shorter transluminal anastomosis and predisposes them to obstruction as well as difficult positioning. With the rise in new EUS-guided interventional techniques, new tools, in particular, new stent designs have evolved to facilitate the various applications. A few EUS-specific stents have now become available for EUS-TLD.[4,5] We hereby review the stent designs and discuss lacunae to be addressed to improve the efficacy, safety, and ease of procedures.

Evolving techniques for endoscopic retrograde cholangiopancreatography in gastric bypass patients.

The present review describes the current and evolving techniques available in approaching endoscopic retrograde cholangiopancreatography (ERCP) for patients with Roux-en-Y gastric bypass (RYGB) anatomy. Recent studies have demonstrated that device-assisted enteroscopy (DAE) approaches have high failures rates when performing ERCP, but are currently considered the first-line approach for patients with RYGB anatomy because of lower costs and risks compared to surgery. In contrast, laparoscopicy-assisted-ERCP (LA-ERCP) exhibits high technical success rates but carries surgical risks and requires a high degree of scheduling coordination. A novel, completely endoscopic approach called endoscopic ultrasound directed transgastric ERCP (EDGE), also known as gastric access temporary for endoscopy (GATE), has in recent years shown high ERCP success rates comparable to LA-ERCPs while obviating the need for surgical assistance. ERCP is technically difficult in patients with RYGB anatomy. Numerous approaches to ERCP exist, although availability of these techniques may be limited and depend on institutional expertise. The best initial approach should be considered based on patient history and institutional factors.

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.

Treatment of Biliary Stent Complications in a Patient With Roux-En-Y Gastric Bypass Using Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): A Case Report

Treatment of Biliary Stent Complications in a Patient With Roux-En-Y Gastric Bypass Using Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): A Case Report

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.