Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)-guided gallbladder drainage can be combined in one session [1 ] but remain challenging in postsurgical anatomy [2 ]. EUS-directed transgastric ERCP has led to favorable results in Roux-en-Y gastric bypass; several other through-the-stent endoscopic procedures are also possible in gastric bypass, including EUS [3 ]. ERCP may similarly be performed in Roux-en-Y hepaticojejunostomy by creating a fistula from the stomach or duodenum to the afferent limb using a lumen-apposing metal stent (LAMS) [4 ].
An 88-year-old woman who had undergone subtotal gastrectomy for gastric adenocarcinoma experienced cholecystitis with common bile duct (CBD) stones. Access to the papilla using ERCP failed. EUS-guided antegrade stone removal was attempted. Lack of intrahepatic dilation precluded transhepatic EUS-guided cholangiography. The CBD was imaged transgastrically under EUS and punctured through the hepatic artery and portal vein with a 22G needle ([Fig. 1 ]). Methylene-blue cholangiography confirmed the presence of multiple CBD stones. Contrast outflow into the duodenum provided fluoroscopic mapping ([Fig. 2 ]). EUS-puncture of the duodenum from the jejunum next to the surgical gastrojejunostomy using a 19 G needle confirmed access by aspiration of blue-tinged fluid. Saline injection through the 19 G needle brought about luminal distension prior to freehand duodenal insertion of a cautery-enhanced 20 × 10-mm LAMS at the duodenojejunal flexure ([Video 1 ]). After balloon dilation of the LAMS to 18 mm, the echoendoscope was removed. A duodenoscope was passed through the LAMS retrogradely to the papilla ([Fig. 3 ]). CBD stones were cleared following over-the-stent needle-knife sphincterotomy and balloon sphincteroplasty. The duodenoscope was removed. An echoendoscope was advanced through the LAMS into the duodenal bulb under careful fluoroscopic monitoring ([Fig. 4 ]). A 10 × 10-mm LAMS was advanced freehand under EUS and deployed for cholecystoduodenostomy ([Fig. 5 ]). After cholestasis and symptom resolution, the patient was discharged without further event.
Fig. 1 Ultrasound view of the endoscopic ultrasound (EUS)-guided transvascular puncture of the common bile duct using a 22G needle. CBD, common bile duct.
Fig. 2 Fluoroscopic view of EUS-guided transportal methylene-blue cholangiography confirming multiple choledocholithiasis. Contrast outflow from the common bile duct through the major papilla outlines the duodenum and proximal jejunum on fluoroscopy.
Video 1 Endoscopic ultrasound (EUS)-guided transportal cholangiography and jejunoduodenostomy with a lumen-apposing metal stent allowing through-the-stent retrograde passage of the duodenoscope and echoendoscope for single-session endoscopic retrograde cholangiopancreatography and EUS-guided gallbladder drainage in a patient with Roux-en-Y gastrectomy.
Fig. 3 Endoscopic retrograde cholangiopancreatography through the lumen-apposing metal stent (LAMS), monitored by fluoroscopy. Additionally, choledocholithiasis demonstrated on retrograde cholangiography.
Fig. 4 Fluoroscopic view of the echoendoscope passage through the LAMS to access the duodenal bulb. Inset: Endoscopic view of the jejunoduodenostomy.
Fig. 5 Endoscopic ultrasound view of freehand placement of a 10 × 10-mm LAMS for cholecystoduodenostomy.
Through-the-LAMS ERCP appears feasible in gastrectomy patients, as in other patients with postsurgical anatomy [3 ]
[4 ]. Transportal EUS-guided puncture may safely be performed for tissue sampling [5 ]; it may also allow EUS-guided cholangiography in postsurgical anatomy without intrahepatic dilation, facilitating afferent limb mapping on fluoroscopy. Transenteric LAMS allow sequential endoscope passage for combined ERCP and EUS-guided gallbladder drainage as a same-session procedure in high-surgical-risk Roux-en-Y gastrectomy patients.
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