Single-step endoscopic ultrasound-guided gastroenterostomy and ERCP in patient with Roux-en-Y hepaticojejunostomy after right lobe hepatectomy

• References

Since endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent was introduced first in an animal model in 2012 [1], and then in humans in 2015 [2], this technique has become more and more promising; it is now used in many expert centers around the world [3] to treat gastric outlet obstruction and to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy.

A 32-year-old woman with a history of right hepatectomy for a Klatskin IIIb cholangiocarcinoma (pT4N1pM1), with Roux-en-Y hepaticojejunostomy and incomplete chemotherapy, was referred to our center for sepsis with cholestasis and cytolysis. CT scan revealed a dilated intrahepatic bile duct and dilated afferent jejunal limb in contact with carcinoid lymph node metastasis ([Fig. 1], [Video 1]). After multidisciplinary discussion, we decided to perform an endoscopic ultrasound-directed transgastric ERCP (EDGE) in one single session. First, under sonographic guidance in the stomach, a 10-cm dilated jejunal limb was seen, and a 15-mm Hot Axios stent system (Boston Scientific, New York, USA) was deployed to form a gastroenterostomy. Then we dilated the anastomosis with a 12-mm balloon to facilitate the passage into the jejunal limb of a conventional gastroscope. Next, the biliary anastomotic orifice was located and cannulated with a sphincterotome. Some small dilation of the orifice was achieved through repeated passing of the sphincterotome ([Fig. 2], [Fig. 3]). In this way we achieved good emptying of the bile duct without the need for biliary stenting at the end of the procedure ([Fig. 4]). No related adverse event occurred after the procedure. The patient was discharged home 24 h later with significant clinical improvement and continued oral antibiotics.

Video 1 Single-step endoscopic ultrasound-guided gastroenterostomy and ERCP in patient with Roux-en-Y hepaticojejunostomy.

EDGE was initially reported in 2015 as a two-stage procedure to minimize the risk of stent dislodgment [4], and was not then recommended for urgent cases. In this report, we wish to demonstrate its feasibility and safety as a single-step procedure. Moreover, despite the high cost of the Hot Axios system, in a comparison with other current alternative strategies for Roux-en-Y anastomosis, EDGE was shown to be the most cost-effective [5]. Thus, shortening the procedure into a single session should reduce even further the cost of patient management.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Binmoeller K, Shah J. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 2012; 44: 499-503
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar
• 2 Khashab MA, Kumbhari V, Grimm IS. et al. EUS-guided gastroenterostomy: the first US clinical experience (with video). Gastrointest Endosc 2015; 82: 932-938
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 3 McCarty TR, Garg R, Thompson CC. et al. Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2019; 7: E1474-E1482
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar
• 4 Kedia P, Kumta NA, Widmer J. et al. Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique. Endoscopy 2015; 47: 159-163
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar
• 5 James HJ, James TW, Wheeler SB. et al. Cost-effectiveness of endoscopic ultrasound-directed transgastric ERCP compared with device-assisted and laparoscopic-assisted ERCP in patients with Roux-en-Y anatomy. Endoscopy 2019; 51: 1051-1058
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar

Corresponding author

• References

• 1 Binmoeller K, Shah J. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 2012; 44: 499-503
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar
• 2 Khashab MA, Kumbhari V, Grimm IS. et al. EUS-guided gastroenterostomy: the first US clinical experience (with video). Gastrointest Endosc 2015; 82: 932-938
  MissingFormLabel

  CrossrefPubMedSuche in Google Scholar
• 3 McCarty TR, Garg R, Thompson CC. et al. Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2019; 7: E1474-E1482
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar
• 4 Kedia P, Kumta NA, Widmer J. et al. Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique. Endoscopy 2015; 47: 159-163
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar
• 5 James HJ, James TW, Wheeler SB. et al. Cost-effectiveness of endoscopic ultrasound-directed transgastric ERCP compared with device-assisted and laparoscopic-assisted ERCP in patients with Roux-en-Y anatomy. Endoscopy 2019; 51: 1051-1058
  MissingFormLabel

  Thieme ConnectPubMedSuche in Google Scholar