EUS-DIRECTED TRANS-JEJUNO-GASTRIC BYPASS ERCPS WITH USE OF 20MM LUMEN-APPOSING METAL STENTS (LAMS) IN A PATIENT WITH ROUX-EN-Y GASTRIC BYPASS (RYGB) DUE TO REFRACTORY BILIARY LEAK

Introduction:

EUS-guided gastrogastromy with LAMS between pouch and gastric remnant of the RYGB gain acceptance to practice ERCP. LAMS migration during the passage of the duodenoscope occurs up to 60%. Deferred ERCP until maturation of the fistula is advised. New 20-mm LAMS have a 25% larger diameter, and could facilitate ERCP, but have not been tested on RYGB yet.

Description:

Woman who undergone a RYGB presents early bile leak post-cholecystectomy. EUS-guided JG-assisted ERCP was performed. The excluded stomach was identified with an echoendoscope from the proximal jejunum and contrast was injected through a 19-G needle to confirm the position within and to distend the stomach remnant. Jejuno-gastrostomy was perform using hot-Axios system and a 20 mm LAMS.

Then, ERCP was performed through the LAMS in the same session. The ampulla of Vater were easily accessed using duodenoscope.

Sphincterotomy and stone extraction were performed and a plastic-10F stent was placed. A week later, new ERCP was performed cause of the persistent bile leak, and the plastic stent was replaced with metal stent and coaxial pigtail stent.

The biliary stent, pigtail stent and LAMS were removed when the bile leak stopped.

the fistula was closed using endoscopic suturing (Overstitch; Apollo Endosurgery) and over-the scope clip (Ovesco).

Conclusion:

We describe the use of 20-mm-LAMS and combined endoscopic closure Ovesco-suturing in RYGB with refractory bile leak. None ERCPs caused stent migration. Thanks to these technical modifications, the endoscopic management did not require any additional session respect to a patient non-RyGB.