IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy. Disclosure of interest: None declared. A 52-year-old ...
Single session one-step EUS-guided gastro-gastrostomy and ERCP in patients with by-pass surgery Ligresti Dario, Amata Michele, Granata Antonino, Barresi Luca, Cipolletta Fabio, Traina Mario, Tarantino Ilaria Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
Objective Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure for morbid obesity. In these patients, access to the major papilla is a real challenge. Alternative approaches, including enteroscopy-assisted or surgery-assisted ERCP, have been reported with a low success rate or high risk of complications, though. Recently, EUS-directed gastro-gastrostomy ERCP (EDGE) was developed as an effective mini-invasive treatment for patients with RYGB. The purpose of this poster is to describe an EDGE with an electrocautery-tipped lumenapposing metal stent (LAMS) and same session ERCP.
Methods A 52-year-old woman with a previous history of cholecystectomy, who underwent RYGB for severe obesity in 2011, presented with fever and biliarytype pain. Laboratory testing revealed elevated transaminase, ALP, and GGT levels. Following abdominal US evidence of mild intrahepatic biliary dilation, a contrast-enhanced MRI showed common bile duct (CBD) dilation and a contrastenhanced, bulging papilla (Fig 1). The patient was then referred to our institute to manage the biliary obstruction. After discussion about different options for accessing the biliary tree, the patient agreed to undergo a one-step, single session EDGE. The bypassed stomach was accessed from the gastric pouch under EUS guidance (Fig 2a,2b) with a 15 mm electrocautery-tipped LAMS (AXIOS-EC, Boston Scientific) creating a gastro-gastrostomy. Following stent dilation, a side-viewing endoscope was inserted through the LAMS to perform standard ERCP (Fig 3). The major papilla was slightly enlarged and covered by normal mucosa. A cholangiogram confirmed CBD dilation. Sphincterotomy was performed, and biopsies of intrampullary protruding tissue were taken.
Results The procedure and post-procedural course were uneventful. A CT scan 24 hours later showed the LAMS correctly in place (Fig 4). Histology was negative for malignancy, LFTs normalized and no more episodes of abdominal pain were referred. Three weeks later LAMS was removed during a follow-up EGD and the fistula was left to close by secondary intention.
Fig 1. Magnetic resonance cholangiopancreatography showing common bile duct dilation.
Fig 2. A) EUS view of bypassed stomach (*) accessed with a 19 G needle (arrow); B) Fluoroscopic view of a guidewire passed A B through the 19 G needle into the contrasted bypassed stomach and down to the duodenum
Fig 3. Fluoroscopic view of a standard duodenoscope through the lumen apposing metal stent (LAMS).
Fig 4. CT-scan 24 hours after procedure showing LAMS (circle) correctly in place.
Conclusion In our experience, the one-step positioning procedure for electrocautery-enhanced LAMS furthers the technical simplicity. In fact, it avoids the need for dissection devices and balloon dilation of the fistulous tract, thus improving safety, and reducing procedure time. We also believe that ERCP in the same session is feasible and safe. Disclosure of interest: None declared
