Peritonoscopy for salvage of gastrogastrostomy tract during EDGE procedure. Primary author Alexis Bayoudin. Additional authors include Kenneth Binmuller, Christopher Hamersky, Rabindra Watson, and Andrew Nett. These are our disclosures. Here we present a case of a 62-year-old woman with a history of a TIA, type 2 diabetes, NASH, hypertension, and history of a Roux-en-Y gastric bypass in 2017 who presented for further evaluation and therapy of cholecystitis and choledocolithiasis. Endoscopic ultrasound demonstrated dilation of the common bile duct to 10 millimeters and one stone in the common hepatic duct measuring 8 millimeters. One 20-millimeter biflange fully-covered lumen-opposing metal stent was deployed to create a gastrogastrostomy. Stent was then dilated to 19 millimeters. A transgastric ERCP was subsequently performed. During scope advancement through the antrum, looping without significant resistance was encountered. Partial scope withdrawal demonstrated that the gastrogastrostomy stent was in position. Repeat advancement through the antrum resulted in further scope looping without progress towards the pylorus. The duodenoscope was then withdrawn again, and the gastrogastrostomy stent was noted to be dislodged from the gastric pouch with the proximal end intraperitoneal and the distal end within the excluded stomach with significant separation of the gastric pouch and excluded stomach. Endoscopic methods include therapeutic endoscope advancement across gastric pouch perforation, peritonoscopy performed with fluoroscopic guidance to reach the migrated stent, gastrogastrostomy salvage with placement of a second 20-millimeter lumen-opposing metal stent through a previously placed migrated stent. Long-limb ERCP was then performed with successful placement of a 7 French by 10 centimeter plastic stent in the common bile duct for acute decompression. Repeat transgastric ERCP performed after gastrogastrostomy maturation with stent removal, biliary sphincterotomy, and stone extraction. Endoscopic ultrasound demonstrated dilation of the common bile duct to 10 millimeters and an 8-millimeter stone found in the common hepatic duct. The excluded stomach was punctured with a standard 19-gauge FNA needle, and the lumen was filled with dilute contrast. A 20-millimeter biflange fully-covered lumen-opposing metal stent was deployed, creating a gastrogastrostomy, and then dilated to 19 millimeters with a TTS 18-19-20 millimeter balloon. Subsequent ERCP and scalp film demonstrated the lumen-opposing metal stent in place. The duodenoscope advanced easily through the lambs into the excluded stomach, but an initial looping without resistance occurred while attempting to enter the bilorus. Upon withdrawal, the distal stent flange remained in position while the gastric stent had migrated out of the gastric pouch, where the stent was initially placed. It was apparent that the scope looping had resulted in distant separation between the gastric pouch and excluded stomach walls. A therapeutic endoscope was advanced through the gastric pouch perforation into the peritoneum. The scope was advanced carefully through the visceral fat for peritoneoscopy to locate the migrated stent and excluded stomach. The lumen-opposing metal stent and excluded stomach were located successfully with fluoroscopic guidance. The excluded stomach was intubated through the lambs and a guide wire was placed to secure access. The proximal stent flange was grasped with rat tooth forceps and was partially retracted back through the gastric pouch fistula. The stent flange could not be fully retracted back into the gastric pouch lumen. A second 20 millimeter lambs was then deployed under direct endoscopic visualization through the previously placed migrated stent. The distal flange was deployed into the excluded stomach and retracted up against the pre-existing lambs. The excluded stomach was then retracted back up against the gastric pouch wall. The proximal end of the second lambs was deployed within the gastric pouch with successful salvage of the gastrogastrostomy tract with no persistent perforation. To achieve acute biliary decompression, long limb ERCP was then performed using a pediatric colonoscope and the rigidizing overtube device. The bioduct was cannulated and a cholangiogram was performed with a filling defect seen in the common hepatic duct. A 7 French by 10 centimeter trans-papillary plastic stent was then placed with good bioflow. The distal lambs flange was visualized from a retrograde approach within the excluded stomach. The proximal lambs flange was visualized within the gastric pouch during scope withdrawal. She had no post-procedure pain and was continued on antibiotics. She underwent laparoscopic cholecystectomy the next day and was discharged home. One month later, she presented for repeat ERCP for stent removal and stone extraction. Repeat ERCP one month later demonstrated the luminoposing metal stents in place. The stents were removed with rat tube forceps without any difficulty. The duodenoscope was reintroduced and able to traverse the mature gastrogastrostomy tract into the duodenum. The previously placed biliary stent was removed and sphincterotomy was performed with balloon sweep and removal of retained stones and sludge. Mild self-limited oozing was present in the gastrogastrostomy tract after lamb's removal. The tract was fully mature. The EDGE procedure allows for successful access of the pancreatic biliary system of patients with challenging Roux-en-Y anatomy. With the increased application of the EDGE procedure, knowledge of techniques to manage complications is necessary. Lamb's dislodgement and perforation are known adverse events of the EDGE procedure. In the setting of lamb's dislodgement into the intraperitoneal space, peritonoscopy for reintubation of the excluded stomach followed by placement of the second lambs can successfully salvage the gastrogastrostomy tract with immediate closure of perforation. Dislodgement of the lambs during the index EDGE procedure is a known reported adverse event. Peritonoscopy with the use of a second lambs to re-oppose the gastric pouch and excluded stomach can be employed for gastrogastrostomy salvage.

EDGE procedure

endoscopic ultrasound-guided transgastric ERCP

cholecystitis

choledocolithiasis

complications