Eastern Virginia Medical School Norfolk, VA, United States
Byung S. Yoo, MD1, Kevin V. Houston, MD2, Ankit Patel, MD3, Parth J. Parekh, MD1 1Eastern Virginia Medical School, Norfolk, VA; 2VCU Health System, Richmond, VA; 3George Washington University School of Medicine and Health Sciences, Norfolk, VA
Introduction: Patients with Roux-en-Y gastric bypass (RYGB) often pose a technical challenge for therapeutic endoscopic procedures and endoscopic ultrasound (EUS) guided procedures proposes an innovative means to overcome this complex anatomy.
Case Description/Methods: A 62-year-old male with a history of obesity (BMI of 44) and RYGB presented with asymptomatic jaundice. CT imaging demonstrated both central intrahepatic duct and extrahepatic common bile duct dilation and lobulated gallbladder debris or sludge. Given the obstructive jaundice in the setting of complex RYGB anatomy and need for an endoscopic retrograde cholangiopancreatography (ERCP), the patient underwent endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-cholecystoduodenostomy via gastric access temporary for endoscopy (GATE) (Video).
After a creation of GATE, attempts were made to advance to the duodenum with a duodenoscope. However, due to a suboptimal lumen apposing metal stent (LAMS) placement ing of the duodenum a linear echoendoscope was instead utilized to navigate the challenging site. The biliary tree was swept for sludge with stones removed. At this time, a decision was made address the gallbladder given the she is a high-risk surgical patient. A linear echoendoscope was introduced through the GATE and identified a thickened gallbladder wall and multiple hyperechoic stones. After a needle puncture through the gallbladder and duodenum under fluoroscopic and EUS guidance, a LAMS was deployed and dilated. The endoscopic suturing device was then used to suture the stent to the wall. Finally, the gallbladder was irrigated and stones were successfully evacuated. The patient tolerated the procedure well and was discharged after a brief post-operative observation.
Discussion: EDGE helps overcome the technical challenges of complex RYGB anatomy. We utilized the linear echoendoscope to provide optimal maneuverability for navigation of difficult anatomy as well as to perform retrograde cholangiopancreatography and EUS-guided cholecystoduodenostomy. Our case represents the first case of EDGE and EUS-cholecystoduodenostomy performed in a single setting in a RYGB patient. We encourage physicians to continue to take advantage of EUS as a tool for navigation in difficult and complex anatomies. Furthermore, performance of a EUS-cholecystoduodenostomy by highly skilled advanced endoscopists should be considered for RYGB patients that are at high risk for surgery or in need of acute intervention.
Disclosures: Byung Yoo indicated no relevant financial relationships. Kevin Houston indicated no relevant financial relationships. Ankit Patel indicated no relevant financial relationships. Parth Parekh indicated no relevant financial relationships.
Byung S. Yoo, MD1, Kevin V. Houston, MD2, Ankit Patel, MD3, Parth J. Parekh, MD1. P1762 - EURCP: One Scope to Rule Them All, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.