Endoscopic ultrasound-directed transduodenal ERCP in a patient with a duodenal switch for complex stone management. These are our disclosures. Endoscopic ultrasound-directed transgastric ERCP, or EDGE, is an innovative technique that allows for access to the biliary tree in patients who have undergone gastric bypass surgery. In an EDGE procedure, a LAMS is placed between the gastric pouch and excluded stomach, which allows an ERCP to be performed in a patient with gastric bypass anatomy who is experiencing biliary pathology. EDGE has become favorable to IR and laparoscopic intervention due to its high success and high safety profile. There is little documented on EDGE methodology being performed in a patient with duodenal switch anatomy. Unlike gastric bypass, a duodenal switch involves creating a duodenal jejunal anastomosis between the first part of the duodenum and the jejunum. The remainder of the duodenum and the biliary tree are left intact. However, they are excluded from the direct path of food emptying from the stomach and through the duodenal jejunal anastomosis. The bile will ultimately converge with the part of the jejunum that was involved in the duodenal jejunal anastomosis via a more distal jejunal jejunal anastomosis. Therefore, to apply EDGE methodology to a duodenal switch, the most direct route to performing endoscopic intervention on the biliary tree is by forming a communication between D1 and D2. The patient is a 69-year-old male with a past medical history of non-Hodgkin lymphoma and obesity who underwent gastric sleeve and duodenal switch in 2003. One year prior to presentation to our hospital, the patient presented with jaundice and sepsis due to biliary obstruction and at the time IR performed CT-guided biliary stenting with a fully covered metal stent left in situ. One year after IR intervention, the patient re-presented with right upper quadrant pain and jaundice, now requiring definitive management of his disease. The decision was made to attempt EDDE for biliary drainage. In the EDDE technique, a LAMS is placed between D1 and the excluded D2 portion of the duodenum under EUS guidance, as seen in the figure on the right. This D1 to D2 connection allows access to the biliary tree in order to perform an ERCP. The first part of this procedure required utilizing EUS and fluoroscopy to identify the D2 portion of the duodenum. The D2 portion of the duodenum was confirmed by advancing the endoscope to D1 and using a needle to inject contrast into the biliary tree and subsequently observing the contrast runoff from the biliary tree into D2. A duodenal loop was identified on endoscopic ultrasound and was successfully punctured with a 19-gauge needle. Contrast was then injected and confirmed placement of the needle into the duodenum. A 15-millimeter lumen-opposing metal stent was placed between D1 and D2. The LAMS was subsequently dilated to form the initial anastomosis between D1 and the excluded D2. A double pigtail stent was then placed into the lumen of the LAMS for stent anchoring. Bile was observed flowing from the lumen of the LAMS. One month later, the patient returned for the second part of the procedure. The D1 to D2 anastomosis can be seen from the previous procedure and the LAMS and double pigtail stent are well visualized. The D2 portion of the duodenum is seen and the major papilla is identified with evidence of a prior sphincterotomy and an in-migrated metal stent. The duodenoduodenal LAMS was subsequently exchanged and the LAMS was upsized from 15 millimeters to 20 millimeters. The major papilla was then cannulated. Contrast was injected to visualize the biliary tree and there was a filling defect seen concerning for a stone. Multiple attempts were made to remove the previous papilla. A balloon sweep of the common bile duct was attempted. This was followed by an attempt to dilate the entire main bile duct. However, there was poor clearance of the stone debris in the duct. The decision was then made to place a second bile duct. This was followed by an attempt to dilate the entire main bile duct. However, there was poor clearance of the stone debris in the duct. The decision was then made to place a trans-papillary covered metal stent into the common bile duct through the previously placed stent for later removal via stent-in-stent technique. To conclude this portion of the procedure, a trans-papillary double pigtail stent was placed coaxially through the newly placed metal stent. Three months later, the trans-papillary metal stent and the double pigtail stent were visualized and the double pigtail stent was removed using rat-tooth forceps. The recently placed trans-papillary covered metal stent was then removed using a snare. The in-migrated metal stent was removed via piecemeal technique with the rat-tooth forceps. This in-migrated stent was then removed using a snare. The trans-papillary metal stent was removed via piecemeal technique with the rat-tooth forceps. This in-migrated stent was able to be removed completely using this technique. A wire was passed into the biliary tree, followed by bile duct cannulation. The biliary tree was swept with a 12mm balloon starting at the bifurcation. Stones, stone debris, and sludge were swept from the duct. Four months later, the patient returned for the final portion of the procedure. The duodenal enterostomy in the first part of the duodenum was visualized and widely patent. The lambs forming the duodenal enterostomy was then removed using rat-tooth forceps, leaving a patent duodenoduodenal fistula. The duodenoduodenal fistula was then inspected with evidence of mild oozing but otherwise healthy appearing mucosa. Contrast was injected through the enterostomy to ensure there were no adverse events or leak. Following the procedure, the patient was completely asymptomatic and the decision was made to leave the patient stent-free. The successful completion of this procedure indicates that it may be safe and effective to perform an EDDE procedure in patients who have previously undergone a duodenal switch. In conclusion, an EDDE procedure was successfully performed between D1 and the excluded D2 portion of the duodenal switch. Performing an EDDE is a practical method to perform ERCP in patients with duodenal switch anatomy. More EDDE cases are needed to further elucidate the efficacy, safety profile, and long-term success of this procedure.

Endoscopic ultrasound

Transduodenal ERCP

Lumen-apposing metal stent

Duodenal switch

Stone management