P1729 - Spontaneous Fistula Lending to Unique EUS-Directed Transoral ERCP Approach in Patient With Roux-en-Y Gastric Bypass

Sadie De Silva, MD¹, Susan Y. Li, BS², Brandon T. Nguyen, BS², Duminda Suraweera, MD³, Kumaravel Perumalsamy, MD³, Vivaik Tyagi, MD^3
1UHS Southern California Medical Education Consortium, Temecula, CA; ²Western University of Health Sciences, Lancaster, CA; ³Gastro Care Institute, Lancaster, CA

Introduction: Exclusion of the stomach after Roux-en-Y gastric bypass (RYGB) makes conventional endoscopic retrograde cholangiopancreatography (ERCP) technically challenging due to the altered anatomy. Recently, endoscopic ultrasound-directed transgastric ERCP (EDGE) has provided an innovative solution to this via the creation of a gastrogastric fistula (GGF).

Case Description/Methods: Here, we present a 6o-year-old female with past medical history of RYGB in 1990 who presented with abdominal pain and was found to have abnormal liver function tests and magnetic resonance cholangiopancreatography revealing an 8 mm filling defect in distal common bile duct with dilation of the duct to 15 mm in diameter. Subsequently, an endoscope was inserted and advanced to the Roux-en-Y anastomosis, however could not be advanced beyond this point. On withdrawal, the stomach was carefully examined revealing a pinhole opening. It was cannulated with a guidewire and a ERCP cannula was advanced. Contrast was injected to confirm position within the excluded stomach. Over the guidewire, a 15 mm x 10 mm fully covered AXIOS stent was placed under fluoroscopy and direct visualization. Subsequently, antegrade passage of the endoscope through the GGF was performed and advanced to the major ampulla. After canulation, cholangiogram was obtained and showed a dilated duct up to 15 mm with a distal filling defect. Sphincterotomy was performed and a balloon was used to successfully remove a black stone and sludge. The patient’s liver function tests improved and eventually normalized on follow up.

Discussion: ERCP in patients with Roux-en-Y gastric bypass requires careful planning given altered anatomy. Traditionally it has been performed using balloon-assisted enteroscopy, laparoscopic-assisted ERCP and, more recently, endoscopic ultrasound (EUS)-guided transgastric approach with creation of a transluminal fistula into the excluded stomach for ERCP (1). In our patient, a spontaneous GGF allowed for unique access point for a transoral approach. It is estimated that about 1-2% of patients who now undergo RYGB will develop a GGF, with historical surgeries having much higher incidences (2). Upper gastrointestinal series remains the gold standard for diagnosis of GGF with computed tomography (CT) being used more recently. This case distinctively demonstrates the importance of careful examination and evaluation for GGF in RYGB patients needing ERCP as it may provide an access point for ERCP.



Disclosures:


Sadie De Silva, MD¹, Susan Y. Li, BS², Brandon T. Nguyen, BS², Duminda Suraweera, MD³, Kumaravel Perumalsamy, MD³, Vivaik Tyagi, MD³. P1729 - Spontaneous Fistula Lending to Unique EUS-Directed Transoral ERCP Approach in Patient With Roux-en-Y Gastric Bypass, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.