The EDGI new take on EDGE: EUS-directed transgastric intervention (EDGI), other than ERCP, for Roux-en-Y gastric bypass anatomy: a multicenter study

Abstract

Background and study aims Indications for accessing the duodenum, and/or excluded stomach in Roux-en-Y gastric bypass (RYGB) patients extend beyond diagnosis and treatment of pancreaticobiliary maladies. Given the high technical and clinical success of EUS-directed transgastric ERCP (EDGE) in RYGB anatomy, we adopted this transgastric (anterograde) approach to evaluate and treat luminal and extraluminal pathology in and around the excluded gut in RYGB patients. EUS-directed transgastric intervention ("EDGI"), other than ERCP, is the terminology we have chosen to describe this heterogenous group of transgastric diagnostic and/or interventional endoscopic procedures (transgastric interventions) performed via a lumen-apposing mental stent (LAMS) in select patients with RYGB. Patients and methods A multicenter (n = 4), retrospective study of RYGB patients with suspected luminal or extraluminal pathology, in or around the duodenum and/or excluded stomach, underwent EDGI using LAMS between December 2015 and January 2019. Results A total of 14 patients (78.6 % women; mean age, 55.7 + 12.4 years) underwent EDGI via LAMS. Technical and clinical success rates of EDGI were 100 %. The most common transgastric interventions were diagnostic EUS of extraluminal pathology (n = 6, 42.7 %) and endoscopic biopsy of gastroduodenal luminal abnormalities (n = 5, 35.7 %). Two moderate-severity adverse events due to LAMS maldeployment occurred during EUS-JG creation (14.3 %), and each instance was successfully rescued with a bridging stent. Conclusions A variety of gastroduodenal luminal and extraluminal disorders in RYGB patients can be effectively diagnosed and managed using EDGI via LAMS.

Fig. 1 GRAPHICAL ABSTRACT

Illustrated depiction of EUS-directed transgastric intervention (EDGI) for management of walled-off necrosis (WON) in Roux-en-Y gastric bypass anatomy. Endoscopic access to the gastric remnant is provided by way of a gastrogastric fistula created via a lumen-apposing metal stent (LAMS). A second LAMS is used to drain the WON through the gastric remnant.

Fig. 2 a

CT abdomen/pelvis (coronal section) demonstrating a pancreatic walled-off necrosis (WON) adjacent to the gastric pouch in a Roux-en-Y gastric bypass (RYGB) patient. b CT abdomen/pelvis (coronal section) demonstrating the pancreatic WON adjacent to the gastric pouch and gastric remnant, after EUS-directed jejunogastric (JG) fistula creation with a 20-mm × 10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot AXIOS stent and delivery system; Boston Scientific, Marlborough, Massachusetts, United States). c Fluoroscopic image of a linear echoendoscope (GF-UCT180; Olympus, Central Valley, Pennsylvania, United States) inserted through a 20-mm × 150-mm esophageal fully covered self-expanding metal stent (FCSEMS) (Niti-S through-the-scope esophageal stent; Taewoong Medical, Seoul, Korea) that was placed through the jejunogastric LAMS. The esophageal FCSEMS was placed through the JG 20-mm LAMS to readjust the angle of the LAMS so that the linear echoendoscope could be passed into the gastric remnant without LAMS dislodgement. A previously placed 10-Fr × 9-cm straight plastic pancreatic duct stent is visible. d Fluoroscopic image of a newly deployed 15-mm × 10-mm LAMS between the pancreatic WON and gastric remnant (cystgastrostomy). The esophageal FCSEMS within the JG LAMS, and the pancreatic duct stent, are visible. e CT abdomen/pelvis (coronal section) demonstrating a nearly resolved pancreatic WON, with the LAMS cystgastrostomy deployed between the WON and gastric remnant. The proximal end of the esophageal FCSEMS, through the jejunogastric LAMS, is visible. f CT abdomen/pelvis (coronal section) 6-weeks after EUS-directed cystgastrostomy in a patient with a RYGB demonstrating complete resolution of the WON.

Fig. 3 a

Endoscopic view with a therapeutic gastroscope of a perforated duodenal bulb ulcer after insertion through a gastrogastric (GG) 20-mm × 10-mm lumen-apposing metal stent (LAMS). b Endoscopic view after closure of the perforated duodenal bulb ulcer with a hemostatic clip using a therapeutic gastroscope inserted through the GG LAMS.  c Endoscopic view 8 weeks after closure of the perforated duodenal bulb ulcer demonstrated healing of the ulcer. Procedure was performed using a therapeutic gastroscope inserted through the GG LAMS.