This ASG video tip is sponsored by Braintree, maker of the newly approved Souflave and Soutab. Hi, I'm Krishan Aguram, I'm an assistant professor of medicine at Icahn School of Medicine, Mount Sinai, director of Endoscopy at Elmhurst Hospital in Queens, New York. And today we're going to talk about endoscopic ultrasound directed transgastric ERCP with using a disposable scope and suturing. I have nothing to disclose. Since obesity is so prevalent throughout the world, multiple bariatric procedures have been performed with the most common being the Roux-en-Y gastric bypass. Due to the rapid weight loss, 29 to 36% of patients can develop gallstones post-bariatric procedure, of which only 5.3% require ERCP. ERCP is still the most commonly used procedure to remove bariatric stones, but due to the abnormal anatomy, there are multiple challenges that can impede clinical success. As you can see, in a Roux-en-Y gastric bypass, in the blue color, you'll see the gastric pouch with a gastric jejunostomy, and the green, you have the extruded stomach. To reach this area through an endoscope, either double balloon or single balloon, you have to go through the gastric jejunostomy and go retrograde through the jejunal jejunostomy. This can be extremely challenging as we have to do everything in an upside-down fashion. The other option is to get a laparoscopic port placed into the extruded stomach and then doing a routine ERCP, but this is limited with the OR availability and the surgeon's availability. This is where the EDGE procedure becomes very useful. You can use a luminoposy metal stent, as is shown on the left as an example, an Axio stent. It can be placed between the gastric pouch and the remnant stomach. This gives us regular access to do a regular ERCP. To prevent stent migration, the Apollo Oversitch device was there to suture the luminoposy metal stent. Recently, the X-TAC system was also introduced by the Apollo suturing system. This system is much more simpler and able to be used by even non-advanced endoscopists. In situations where cholangiitis is present, disposable ERCP scopes are currently being used to prevent infection control, but have not been used in EDGE procedures. We will demonstrate the EDGE procedures using a disposable scope and suturing via X-TAC system. A 50-year-old female with history of morbid obesity ruined white gastric bypass presented with a right upper coronary pain, fever, and jaundice, consistent with cholangiitis. Blood pressure was 110 by 70 with a normal heart rate. Labs demonstrated a white count of 20,000 billion 7 with CT scans showing dilated CBD. On initial endoscopy, as we went down, we can see the gastric pouch with the gastrogygianostomy in place. An endoscopic ultrasound was subsequently used to find the extruded or remnant stomach, as you can see with the green arrow. A 19-gauge FNA needle was used to puncture the remnant stomach. An infusion of contrast, water, and methylene blue was injected. A lumino-posimetal stent with cautery was used to deploy the external flange in the remnant stomach and then into the gastric pouch. It is reassuring to see methylene blue and contrast coming from a lumino-posimetal stent. We then use the X-Stack system to go through the stent and in the outside of the stent to fix the stent in place. We try to do this in two different locations on the lamb's stent so as to fix it in place. We later balloon dilate the stent so as to gain access into the remnant stomach. We usually go up to 20 millimeters because a stent is usually 20 millimeters in size. We used a regular EGD scope to go into the remnant stomach and find the pylorus and go to the duodenum while we're visualizing it on fluoroscopy. We later use a disposable scope which is a little bit more stiffer and more challenging but try to pass through the axial stent and into the duodenum with fluoroscopic and regular visualization. We cannulate the bile duct and pus starts coming out of the bile duct. We later start doing a sphincterotomy at which point more pus and a stone falls out from the duct. In six weeks time, we go back to visualize the axial stent as we need at least 46 weeks for the fistula to form before we can remove the axial stent. As you can see, there's a large amount of debris that is present inside the stent as patient did have a full meal the night before. We usually like the patients to be on clear liquid diet the day before. We use a suture cutter to find the area of the suture and the localized area and cut it to free the stent from the mucosa. For the X-tach that is inside the axial or lumen-opposing stent, we attach a Boston 360 clip and without fully deploying it, turn it in a counterclockwise mechanism to unscrew the X-tach from the stent and remove it. Sometimes this could be challenging to get right on the edge to rotate it, but with simple manipulation you'll be able to do it. When all sutures have been removed, we then go to a rat tooth grasper to grasp the device and pull it out of the stomach and remove it completely. To prevent fistula formation, which can occur in 10%, we usually A-B-C the site and close the original defect with more X-tach or over-stitch suturing. It is important to know which type of bariatric procedure was performed as there are only limited amount of procedures that will use the lumen-opposing metal stent for ERCP access. You should also have a good knowledge of using the axial stent or other LAMS devices. Suturing can be done with the over-stitch, but even if you're not very familiar with the over-stitch, the X-tach system can be used, although a little bit more challenging to remove those. Disposable scopes are stiffer than regular scopes and may cause a slight challenge in going through the LAMS, but can be utilized in edge procedures. Remember to perform A-B-C and closure of the gastro-gastric fistula to prevent weight regain as there's a 10% chance of fistula formation.

ERCP procedures

bariatric surgery

EDGE procedure

luminal-positional metal stent

cholangitis