Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP.

Until recently, patients with Roux-en-Y gastric bypass had the options of enteroscopy-assisted or surgery-assisted ERCP. However, the use of a lumen-apposing metal stent (LAMS) with EUS to create a transgastric fistula allows for ERCP with a duodenoscope (EUS-directed transgastric ERCP [EDGE]). However, dislodgement of the LAMS with advancement of the endoscope can result in a perforation, leading some providers to do this in 2 stages: LAMS placement followed by fistula maturation (7-14 days) and subsequent ERCP. To avoid this more expensive 2-step approach, and in cases in which waiting is not an option, we describe 5 cases in which an over-the-scope clip (OTSC) or endostitch was used to secure the LAMS, allowing a single-stage EDGE (Video 1, available online at www.VideoGIE.org).

Cases and endoscopic methods

Patient 1

A 41-year-old man with a 200-cm combined Roux-en-Y bypass and afferent limb length presented with gallstone pancreatitis and a retained common bile duct stone (Fig. 1). A 15-mm cautery-enhanced LAMS was used for the EDGE (Fig. 2). This was secured to the gastric pouch with a single 11/6t OTSC (Fig. 3). After balloon dilation of the LAMS, ERCP was performed to remove multiple black pigmented stones successfully. The patient returned 2 weeks later to have the LAMS removed using argon plasma coagulation to cut the OTSC (Fig. 4). Spontaneous transgastric fistula closure was allowed and was confirmed by an upper-GI series 4 weeks later (Fig. 5).

Figure 1

CT scan demonstrating pancreatitis and a distal common bile duct stone in Patient 1.

Figure 2

Use of 15-mm cautery-enhanced lumen-apposing metal stent to create a gastrogastric fistula in Patient 1.

Figure 3

Lumen-apposing metal stent secured to the gastric pouch with an 11/6t over-the-scope clip in Patient 1.

Figure 4

Use of argon plasma coagulation to cut and remove the over-the-scope clip securing the lumen-apposing metal stent in Patient 1.

Figure 5

Upper-GI series confirming closure of gastrogastric fistula 4 weeks after removal of lumen-apposing metal stent in Patient 1.

Patient 2

A 48-year-old woman with a 180-cm combined Roux-en-Y bypass and afferent limb length was admitted with pain and suspected choledocholithiasis. She underwent successful EDGE with a 15-mm cautery-enhanced LAMS. This was secured with 2 sutures to the gastric pouch (Fig. 6). A biliary sphincterotomy with removal of sludge was successfully performed. Four weeks later the LAMS was removed, allowing spontaneous fistula closure, which was confirmed by an upper-GI series 6 weeks later.

Figure 6

Lumen-apposing metal stent secured with 2 sutures to the gastric pouch in Patient 2.

Results

Five patients (3 women, 2 men) with a mean age of 52 years (range, 32-71 years) underwent single-stage EDGE from June 2015 to August 2017. The indications for ERCP were choledocholithiasis in 3 patients and pancreatitis in 2 patients. EDGE was performed rather than enteroscopy-assisted ERCP in 4 patients because the length of the bypassed limb was very long (>180 cm), and pancreas divisum with relapsing pancreatitis was present in 1 patient. The LAMS was secured with an OTSC in 1 patient and sutured in 4 patients. All 5 patients underwent successful ERCP with a standard duodenoscope without LAMS dislodgement or adverse events (Tables 1 and 2). Although OTSC placement was faster (3 minutes vs 12 minutes to suture), advancement of the scope through the OTSC-secured LAMS and removal of the OTSC was technically more difficult, which is why after the first case of using the OTSC, a switch was made to suturing.

Table 1

Preprocedural and procedural data on patients undergoing EUS-directed transgastric ERCP with a 15 mm lumen-apposing metal stent (n = 5)

Patient number	Age/gender	Indication	Reason for antegrade approach	Size and type of LAMS	Type of fistula	LAMS secured with	ERCP successful without LAMS dislodgement
1	71/F	Choledocholithiasis	Very long bypassed limb	15 mm, cold	GG	Stitch	Yes
2	41/M	Gallstone pancreatitis	Very long bypassed limb	15 mm, hot	GG	OTSC	Yes
3	48/F	Choledocholithiasis	Very long bypassed limb	15 mm, hot	GG	Stitch	Yes
4	32/F	Relapsing pancreatitis	Pancreas divisum and failed DBE ERCP	15 mm, hot	GG	Stitch	Yes
5	69/M	Choledocholithiasis	Very long bypassed limb	15 mm, hot	GG	Stitch	Yes

DBE, Double-balloon enteroscopy; GG, gastrogastric fistula; LAMS, lumen-apposing metal stent; OTSC, over-the-scope clip.

Table 2

Postprocedural data on patients undergoing EUS-directed transgastric ERCP with a 15-mm lumen-apposing metal stent (n = 5)

Patient number	Hospital stay after procedure (days)	Adverse events	LAMS dwell time in TG fistula (days)	Confirmation of spontaneous TG fistula closure	Follow-up since placement (days)
1	1	No	42	UGI 49 days	502
2	1	No	14	UGI 30 days	286
3	1	No	28	UGI 40 days	282
4	1	No	30	UGI 38 days	245
5	1	No	90	NA	90∗
Mean	1		41		281

NA, Not applicable; LAMS, lumen-apposing metal stent; TG, transgastric, UGI, upper-GI series.

Died of unrelated causes before being able to return for LAMS removal.

The mean LAMS dwell time was 41 days (range, 14-90 days). All patients were allowed to undergo spontaneous fistula closure, which was confirmed by upper-GI series in 30 to 50 days, with a mean follow-up time of 281 days (range, 90-502 days).

Conclusions

A safe, single-stage EDGE can be performed in Roux-en-Y gastric bypass patients without LAMS dislodgement by securing the stent to the gastric pouch with an OTSC or endoscopic stitch. Other options include the use of a pediatric duodenoscope through a 15-mm LAMS or a standard duodenoscope through a 20-mm LAMS. Comparative studies would be useful.

Disclosure

Dr Irani is a consultant for Boston Scientific and Gore Medical. Dr Khashab is a consultant for Boston Scientific, Olympus, and Medtronic and is on the medical advisory boards of Boston Scientific and Olympus. The other author disclosed no financial relationships relevant to this publication.