Javier Tejedor-Tejada, MD1, Ameya A. Deshmukh, BA2, Ahmed M. Elmeligui, MBBCh, MD3, Enad Dawod, MD4, Jose Nieto, DO, FACG5; 1Hospital Universitario Rio Hortega, Valladolid, Castilla y Leon, Spain; 2Midwestern University - CCOM, Downers Grove, IL; 3Kasr Alainy Hospital / Cairo University, Cairo, Al Jizah, Egypt; 4New York-Presbyterian/Weill Cornell Medical Center, New York City, NY; 5Borland Groover Clinic, Jacksonville, FL
Introduction: Gastric bypass is a common operation for weight loss in patients with severe obesity. Gastric access temporary for endoscopy (GATE) is a novel and alternative technique to device-assisted enteroscopy or surgery in patients with post-surgical anatomy secondary to gastric bypass. The GATE procedure involves endoscopic ultrasound (EUS)-guided deployment of a lumen-apposing metal stent (LAMS) to access the remnant stomach to facilitate the drainage of the walled off pancreatic necrotic collection (WON).
Methods: A 60-year-old female patient with a history of gastric bypass surgery and multiple co-morbidities, admitted with the diagnosis of acute biliary pancreatitis. Pre-procedure CT scan identified a WON occupying more than 50% of the pancreatic parenchyma as well as retroperitoneal free liquid. EUS-GATE for management of the WON with a LAMS was deemed to be the best therapeutic option for this patient. A curvilinear echoendoscope was advanced into the gastric pouch to visualize the remnant stomach. Color Doppler imaging was utilized to confirm the lack of significant vascular structures within the needle path prior to needle insertion. A 19-gauge FNA needle was used to create a gastric-gastric access point. Initially, a contrast solution ( > 200cc) was injected into the cavity to fill the remnant stomach and to optimize the target size. Then, under fluoroscopic and EUS-guidance, one 20 x 10 mm LAMS was deployed with cautery enhancement across the tract. Finally, a balloon dilatation catheter was used to dilate the newly created access point to facilitate endoscope passage. Once remnant stomach access was achieved, transgastric EUS-guided drainage of the pancreatic WON occurred using a 15 x 10 mm LAMS. The stent delivery system was inserted directly into the WON using cautery followed by expansion of the distal flange and subsequent expansion of the proximal flange. Discussion: The GATE procedure remains a highly technical and challenging endoscopic procedure. It should only be performed by highly experienced advanced endoscopists with experience in EUS. Possible complications that may occur are bleeding at the GATE access site, risk of non-closure of the fistula, subsequent reversal of the metabolic effect of the bariatric surgery and the risk of dislodgement of the LAMS during the procedure.
Contrast solution injected to confirm target and to increase target size.
Fluoroscopic image of the gastric access for therapeutic endoscopy (GATE).
Expansion of the proximal flange of the LAMS.
Disclosures: Javier Tejedor-Tejada indicated no relevant financial relationships. Ameya Deshmukh indicated no relevant financial relationships. Ahmed Elmeligui indicated no relevant financial relationships. Enad Dawod indicated no relevant financial relationships. Jose Nieto: Boston Scientific – Consultant. ERBE – Consultant.