A 67-year-old woman with history of Roux-en-Y gastric bypass presented for management of acute cholangitis. Magnetic resonance cholangiopancreatography (MRCP) demonstrated extrahepatic bile duct dilatation. The results of her liver chemistry tests were aspartate aminotransferase (AST) 156 IU/L, alanine aminotransferase (ALT) 182 IU/L, total bilirubin 2.6 mg/dL, and alkaline phosphatase 319 IU/L. The patient underwent transgastric endoscopic retrograde cholangiopancreatography (ERCP) using a modified technique merging percutaneous assisted transprosthetic endoscopic therapy (PATENT) [1] and endoscopic ultrasound (EUS)-guided sutured gastropexy for transgastric ERCP (ESTER) [2] ([Video 1]).
An oblique-viewing, linear array echoendoscope was passed into the gastric pouch to identify the excluded gastric remnant. The gastric remnant was punctured with a 19G fine needle aspiration (FNA) needle ([Fig. 1]). Contrast injection confirmed entry of the needle into the excluded stomach. Air (500 mL) was infused through the FNA needle to distend the gastric remnant.
Qualität:
Transgastric endoscopic retrograde cholangiopancreatography (ERCP) being performed in a patient with a Roux-en-Y gastric bypass by combining the percutaneous assisted transprosthetic endoscopic therapy (PATENT) and endoscopic ultrasound-guided sutured gastropexy for transgastric ERCP (ESTER) techniques.
Fig. 1 Endoscopic ultrasound (EUS) image showing the puncture of the excluded stomach using a 19G fine needle aspiration (FNA) needle.
After the remnant was adequately distended, a 19G percutaneous access needle was used to create a gastrostomy. A 450-cm, 0.035-inch biliary guidewire was passed into the excluded stomach and subsequently into the duodenum. The percutaneous access needle was removed leaving the guidewire in place. Three T-fasteners were secured around the guidewire. Graduated dilation of the gastrostomy tract up to 18 Fr was performed. A fully covered esophageal self-expandable metal stent (SEMS; 20 mm × 6 cm) was deployed within the gastrostomy tract. The SEMS was dilated to 18 mm using a high burst pressure balloon dilator. A standard therapeutic duodenoscope was then passed through the SEMS. The bile duct was selectively accessed and cholangiography was performed ([Fig. 2]). Sphincterotomy was followed by sludge removal with an extraction balloon. Following ERCP, a 20-Fr replacement gastrostomy tube was placed. The SEMS was sectioned and removed.
Fig. 2 Cholangiogram obtained via transgastric endoscopic retrograde cholangiopancreatography (ERCP) showing dilatation of the extrahepatic bile duct.
No adverse events occurred. The total procedure time was 80 minutes. The patient was pain-free and was discharged home 2 days later. Repeat laboratory tests 4 days later revealed AST 62 IU/L, ALT 146 IU/L, total bilirubin of 1.2 mg/dL, and alkaline phosphatase 304 IU/L. Removal of the gastrostomy tube was planned for at least 6 weeks after the procedure.
Endoscopy_UCTN_Code_TTT_1AR_2AH
