We will be presenting the trans-LAM suture technique as a novel method to decrease risk of stent migration in single-session EDGE procedures. These are our disclosures. EUS-directed transgastric ERCP, or the EDGE procedure, is an effective approach to gain access to the duodenum and papilla to perform pancreatic cobiliary interventions in patients who have undergone Roux-en-Y gastric bypass. The EDGE procedure utilizes a lumen-opposing metal stent, the LAMs, to create a transgastric fistula that provides access to the excluded stomach and serves as a conduit through which a duodenoscope can be passed. A potential adverse event that can occur with this procedure is stent migration, especially in single-session EDGE procedures, where LAMs placement and the pancreatic cobiliary intervention are performed on the same day. Despite suturing the proximal flange of the LAMs to the gastric pouch, migration can still occur. We present a novel technique of a trans-LAM suture that can provide better stability of the LAMs and decrease the risk of stent migration. Here, we will be discussing a patient with a Roux-en-Y gastric bypass surgery who required urgent ERCP and underwent a single-session EDGE procedure. The trans-LAM suture was performed to increase stent stability and decrease risk of stent dislodgement and perforation. The first step of the EDGE procedure involves placement of the LAMs. Here, a 19A needle is used to access the excluded stomach from the gastric pouch. Diluted contrast is infused through the needle to distend the excluded stomach. A guide wire is passed through the needle and coiled within the excluded stomach. Over the wire, a 20mm LAMs is deployed into the excluded stomach from the gastric pouch under endosonographic guidance. Here you can see the distal flange being deployed in the excluded stomach and tented back against the gastric wall. The proximal flange is then deployed within the gastric pouch as can be seen here. A T2 endoscope with the overstitched suturing system is then used to perform fixation of the proximal flange. A full thickness bite of the gastric pouch has already been taken. You can see another bite being taken through the proximal flange of the LAMs followed by an additional full thickness bite of the gastric pouch. Two sutures are typically placed in this fashion to secure the proximal flange. We now demonstrate placement of the trans-lam suture. We start again by taking a full thickness bite of the gastric pouch. We then drive the scope with the suture across the lambs and take a full thickness bite of the excluded stomach. The scope and the suture are then brought back across the lambs into the gastric pouch where a final full thickness bite is taken to secure the trans-lamb's suture. In the last step, you can see the duodenoscope passing through the lambs with the three sutures in place securing the stent. Although more studies are needed to address this issue, the trans-lams technique provides for an extra suture that anchors the lambs on both sides. We believe that this could limit the risk of stent migration and leads to decreased risk of perforation.

trans-LAM suture technique

stent migration

EDGE procedure

Roux-en-Y gastric bypass

lumen-opposing metal stents