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

Background: 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. Objective: We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). Design: Single-center case series. Setting: Tertiary center with expertise in EUS-guided procedures. Patients: Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. Interventions: 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. Main Outcome Measurements: Technical and clinical success rates as well as adverse events. Results: 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. Limitations: Small sample, single-institution experience. Conclusion: 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.