Two clues make a proof: EUS-directed transgastric ERCP in twice-surgically altered anatomy-Roux-en-Y gastric bypass conversion of a sleeve gastrectomy

Abstract

Video 1EUS-directed transgastric ERCP in twice-surgically-altered anatomy: Roux-en-Y gastric bypass conversion of a sleeve gastrectomy.

Figure 1

The gastric remnant with a “sand dollar” sign was identified by the postanastomotic jejunum under EUS guidance and punctured with a 19-gauge needle. Subsequently, it was dilated using a mixture of saline and contrast medium to create the operative space for freehand placement of an electrocautery-enhanced lumen-apposing metal stent.

Figure 2

Gastric remnant ad duodenum. The injection of contrast depicted a small gastric remnant and, following its flow, the duodenum downstream of the pylorus.

Figure 3

Release of the electrocautery-enhanced lumen-apposing metal stent. After adequate distension of the gastric remnant, a jejunogastrostomy was created by advancing a 20- × 10-mm electrocautery enhanced lumen-apposing metal stent (Hot Axios; Boston Scientific, Marlborough, Mass, USA) by freehand technique. The release of the distal flange occurred under EUS (A) and fluoroscopic (B) control, while the release of the proximal flange was performed under endoscopic visualization.

Figure 4

Through-the-LAMS ERCP. The patient was readmitted after 2 weeks to undergo elective through-the-LAMS ERCP. The LAMS was anchored via 2 endoclips. The jejunal loop was intubated with a standard duodenoscope, and the LAMS was traversed under endoscopic visualization (A) and fluoroscopic control (B). The pylorus was located just downstream of the LAMS (A). LAMS, Lumen-apposing metal stent.

Figure 5

Through-the-LAMS ERCP. After easily passing through the pylorus, the endoscope was pulled into a “short” position in the duodenum. A standard ERCP (cannulation, sphincterotomy, and balloon swipes) was performed. Cholangiography shows the duodenoscope transversing the LAMS and confirmed the presence of a 5-mm stone in the common bile duct. LAMS, Lumen-apposing metal stent.

Figure 6

Through-the-LAMS EUS. A, Two months after the ERCP, the patient underwent a through-the-LAMS EUS using a linear echoendoscope. B, Scanning from the bulb as well as the second duodenal portion revealed no direct or indirect signs of choledocholithiasis. Therefore, the LAMS was removed. LAMS, Lumen-apposing metal stent.

Figure 7

Argon plasma coagulation of the jejunogastric fistula. After the removal of the lumen-apposing metal stent, the jejunogastric fistula was treated with argon plasma coagulation to promote spontaneous closure.