P0808 (S1856). - Single Session Endoscopic Ultrasound-Directed Transgastric ERCP (“EDGE”) in Roux-en-Y Gastric Bypass Patient With Pancreatic Mass and Biliary Obstruction With Intentional Maintenance of Gastrogastrostomy
Petr Vanek, MD1, Shawn Mallery, MD2, Martin L. Freeman, MD, MACG2, Guru Trikudanathan, MD2; 1University of Minnesota (and Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic), Minneapolis, MN; 2University of Minnesota, Minneapolis, MN
Introduction: Pancreatobiliary access in Roux-en-Y gastric bypass (RYGB) anatomy is challenging. With this in mind, endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE), a minimally invasive and completely endoscopic approach, has been developed. It utilizes a lumen-apposing metal stent (LAMS) to reconnect the bypassed stomach by creating gastrogastrostomy, thus facilitating access without the need for surgery or deep enteroscopy. The RYGB reversal carries a risk of weight gain. However, it may be an actual desire in selected cases and make it a favorable choice.
Methods: A 54-year-old female with RYGB was referred for painless jaundice and elevated liver function tests. CT revealed an irregular pancreatic mass causing biliary obstruction. Given the need to obtain biopsy as well as biliary decompression in altered anatomy, the plan was to perform EDGE. EUS showed a locally invasive 49x48mm mass within the pancreatic head and neck. EUS-guided fine-needle aspiration biopsy was performed through the gastric pouch. Preliminary on-site cytology was concerning for pancreatic adenocarcinoma. The gastric remnant was then located through the pouch and accessed with an EUS needle. Contrast material and water were instilled to confirm position and distend the excluded stomach. EUS-guided gastrogastrostomy was established using electrocautery system. Subsequently, a 20mm LAMS was deployed under fluoroscopic and sonographic visualization, reconnecting the bypassed stomach. The stent was then balloon-dilated allowing endoscopic traversal into the duodenum. ERCP ensued immediately confirming distal biliary stricture with upstream dilatation. Following biliary sphincterotomy, a 10mm-by-8cm uncovered metal biliary stent was placed across the stricture. After the procedure, the patient's liver function tests normalized, final cytology confirmed pancreatic adenocarcinoma, and she was started on palliative chemotherapy. The LAMS was left in situ to maintain access and to induce weight gain.
Discussion: Selecting EDGE as the appropriate approach was based on the clinical context and available expertise. In our case, both parts (LAMS placement and ERCP) along with tissue sampling were performed successfully in the same session, preventing delay in neoadjuvant or palliative chemotherapy in a jaundiced pancreatic cancer patient. Moreover, rendering RYGB ineffective was desirable with expected weight loss with cancer progression. In addition, LAMS secured permanent access for potential future interventions.
Disclosures: Petr Vanek indicated no relevant financial relationships. Shawn Mallery indicated no relevant financial relationships. Martin Freeman indicated no relevant financial relationships. Guru Trikudanathan indicated no relevant financial relationships.