Tips and tricks when an EDGE fails. Challenge of severe looping in a large gastric pouch and hiatal hernia. Here are disclosures. EUS guided transgastric interventions. EUS guided gastrogastrostomy or jejunogastrostomy creation allows passage of the endoscope into the excluded stomach facilitating biliary and pancreatic intervention. Although EDGE has a high technical success rate there can be some failures. These are typically due to anatomic restrictions such as large hiatal hernias in which not only the pouch but the excluded stomach may reside, resection of portions of the excluded stomach, large pouch leading to looping of the endoscope. One cannot predict endoscope looping and its challenges till the lamps has been placed and the anastomosis has been created. Ways to mitigate challenges with EDGE. Keeping an axis that leads straight into the excluded stomach and a trajectory to the pylorus. This is often done by using fluoroscopic guidance at the time of placement. Avoid the antrum as a target. Has its own challenges of stent migration due to deterioration forces. Friction across the lamps can be mitigated by using a 20 millimeter lamps and lubricating the scope really well. Here we present a case of a large gastric pouch combined with the hiatal hernia that almost led to an unsuccessful procedure. 67 year old female with history of Roux-en-Y gastric bypass, remote smoker, presence with recurrent acute pancreatitis. She had eight episodes in the last two years. She also had a 10 pound weight loss and does not have diabetes. CT and MRI were performed. CT showed no evidence of a definitive mass or stones and CA 99 was normal. MRCP with secretin was notable for main pancreatic duct structure with upstream dilation and changes consistent with chronic pancreatitis. A large gastric pouch was noted using EOS and fluoroscopic guidance. A direct puncture edge was performed using a 20 millimeter by 10 millimeter lamps followed by a balloon dilation to 19 millimeter. Lamps were secured with two endoscopic sutures. The echo endoscope was then passed across the lamps. We could obtain reasonable views from the stomach and no mass was noted in the pancreas. Duodenum scope had similar looping in the gastric pouch and was unable to traverse the pylorus but we were able to pass a forward-viewing endoscope into D2 with some resistance across the lamps. Things tried but failed. Balloon dilation of the pylorus to 20 millimeters to allow easier intubation despite looping. Passing the same CRA balloon downstream into third part of the duodenum to try and pull the endoscope across the pylorus. Tried with underwater immersion alongside a guide wire in the duodenum and even turning the patient left lateral and prone. We even tried an ERCP with the forward-viewing therapeutic scope. So at this point further attempts at EOS ERCP were halted with the intention to let the fistula mature and try again due to concerns for the strain being put on a fresh anastomosis. So she was taken for a second endoscopy three weeks later. This time the echo endoscope had a better trajectory and views were obtained from the duodenal station. No mass was noted in the head however features of chronic pancreatitis, biliary sludge and stricture were noted. Attempts at passing the duodenoscope failed again due to marked looping in the gastric pouch and we were unable to intubate the pylorus. The previously attempted measures were tried again but have failed once more. A wire was advanced into the duodenum and the scope withdrawn. A 23 millimeter by 15 centimeter esophageal stent was placed from the excluded stomach to the mid esophagus in an attempt to avoid the large loop being created in the gastric pouch. However the proximal end of the stent dislodged into the pouch due to some resistance of the scope passing through the stent despite it being fully dilated and patent. In order to mitigate that the stent was stitched in place in the esophagus but the vector forces caused the sutures to disrupt and migrate into the pouch. So we tried to place the stent from the duodenum to the pouch hoping to gain duodenal access beyond the lamps. This also failed. We were finally able to pull the esophageal stent back from the duodenal bulb all the way up to the distal esophagus giving us a straight trajectory to the duodenum but the vector forces led to looping in the gastric pouch and dislodged the esophageal stent. Final thought and attempt. Despite lubricating the scope with oil and silicone we thought the final point of resistance might be the lamps itself. So we decided to remove it and attempt duodenal intubation. After removing the lamps the fistula was examined with the forward viewing scope and a wire was placed in the duodenum. The scope was passed alongside the guide wire and attempts were made to traverse the pylorus. Position changes were also attempted at this time but we were unsuccessful. A balloon was placed at the pylorus and inflated. The inflated balloon was used to pull the scope into the duodenum and then deflated. This worked finally. You Pylori structure was treated with a fully covered metal stent. The pancreatic divisum was identified. Balloon dilation and two plastic stents were placed. The lamps that had been removed was then back loaded onto a forward viewing scope by rolling and inserting into the channel at the tip of the scope. The stent is gently pushed out using a rat tooth forceps and deployed across the gastro gastrostomy fistula to maintain access for the next ERCP. Key take-home points. Number one initial assessment should include measurement of the size of the gastric pouch. If medium to large sized one should anticipate possible looping. Number two careful selection of the site of initial lamps placement and endosutures placement if planned for single session interventions. Number three lubrication of the scope shaft when passing across the lamps. Number four when encountering difficulty entering the pylorus attempt balloon dilation of the pylorus and use the balloon to pull oneself into the duodenum. Position changes and water immersion can be tried in conjunction with the above techniques. Number five if this fails consider creating a conduit from the esophagus into the pouch using a fully covered esophageal stent and suture it to the esophagus. Number six if all fails convert to two sessions and remove the lamps in two to three weeks and attempt insertion without the lamps. Conclusion. When duodenal intubation fails despite all attempted techniques during a single session edge consider reattempting the procedure with lamps removal in two to four weeks. Further procedures or studies are needed to confirm the safety of this approach.

endoscopic gastric outlet reduction

hiatal hernias

fluoroscopic guidance

balloon dilation

strategic planning