Endoscopy 2019; 51(04): S110
DOI: 10.1055/s-0039-1681494
ESGE Days 2019 oral presentations
Saturday, April 6, 2019 11:00 – 13:00: Video ERCP 2 South Hall 1A
Georg Thieme Verlag KG Stuttgart · New York

LUMEN-APPOSING METAL STENT (LAMS) DISLODGMENT DURING POST-BARIATRIC ERCP: ENDOSCOPIC BRIDGING WITH A DOUBLE-CHANNEL ENDOSCOPE

S Bazaga
1   Hospital Universitario Rio Hortega, Valladolid, Spain
,
R Sánchez-Ocaña
1   Hospital Universitario Rio Hortega, Valladolid, Spain
,
A Yaiza Carbajo
1   Hospital Universitario Rio Hortega, Valladolid, Spain
,
FJ García-Alonso
1   Hospital Universitario Rio Hortega, Valladolid, Spain
,
M de Benito
1   Hospital Universitario Rio Hortega, Valladolid, Spain
,
C de la Serna Higuera
1   Hospital Universitario Rio Hortega, Valladolid, Spain
,
M Pérez-Miranda
1   Hospital Universitario Rio Hortega, Valladolid, Spain
› Author Affiliations
Further Information

Publication History

Publication Date:
18 March 2019 (online)

 

Introduction:

EUS directed trans-gastric ERCP allows access to the excluded stomach through a gastro-gastrostomy in Roux-en-Y gastric bypass. We similarly fashioned a jejuno-jejunal EUS-guided LAMS anastomosis to allow through-the-stent (TTS) ERCP in a patient with recurrent pancreatitis and duodenal switch (DS), a bariatrically altered anatomy distinctly precluding peroral ERCP. We present techniques for localizing the biliary limb in DS and for managing LAMS dislodgment.

Procedure:

We successfully performed ERCP in DS as a three-stage procedure. Firstly, a EUS-guided hepaticogastrostomy (HG) was performed with a SEMS. Secondly, we placed a nasobiliary drain (NBD) through the HG across the ampulla into the biliary limb. After advancing the EUS scope into the alimentary limb, contrast was injected through the NBD to identify the biliary limb under EUS and fluoroscopic guidance. A 20-mm cautery-enabled LAMS was deployed to create a jejuno-jejunostomy bypass from the alimentary into the biliary limb. After balloon dilation of the LAMS, the papilla was reached through it with a pediatric colonoscope. Needle-knife sphincterotomy over the NBD and sphincteroplasty were performed. During colonoscope withdrawal, the LAMS proximal flange dislodged distally into the biliary limb. Attempts to reposition the LAMS with forceps failed. A second overlapping LAMS was deployed to bridge the peritoneal gap, but failed to hold in place the distally dislodged LAMS. Both LAMS ended up lying across the peritoneal gap. A double-channel endoscope was used to successfully pull with dual traction the proximal flange of the first LAMS back into the second LAMS. Seven weeks later, we removed all stents and sutured the fistula endoscopically.

Conclusion:

EUS allows tailoring entero-anastomoses for ERCP access to the individual bariatric patient anatomy. The risk of LAMS dislodgment during TTS-ERCP is not eliminated by the novel larger diameter LAMS. Dual forceps traction with double-channel endoscope seems simple and effetive to manage LAMS dislodgement.