Bridging the Buried GATE: LAMS-in-LAMS Rescue Technique for Endoscopic Ultrasound–Directed Transgastric ERCP

CASE REPORT Gastric access for temporary endoscopy procedure allows endoscopic ultrasound–directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass (RYGB) anatomy.1 A patient with RYGB and a dilated common bile duct secondary to choledocholithiasis opted for a 2-stage EDGE. Initially, a 20 × 10-mm cautery-enhanced lumen-apposing metal stent (LAMS) was placed and dilated to 18 mm to create gastro-gastric (G-G) access. Delayed by 4 weeks due to a national contrast media shortage, the second stage found the G-G LAMS buried into the remnant stomach wall (Figure 1). To prevent stent migration during endoscopic retrograde cholangiopancreatography, we decided to bridge the buried LAMS by placing another 20 × 10-mm LAMS within (LAMS-in-LAMS), via a noncautery enhanced (cold LAMS) technique (Figure 1). Through-the-scope dilation of the new LAMS to 18 mm anchored the stent for completion of endoscopic retrograde cholangiopancreatography (Figure 1), with successful extraction of choledocholithiasis (Figure 1). Both LAMS were removed using rat-toothed forceps. The buried LAMS was removed using an inversion technique, grasping the distal (nonburied) flange and pulling it into the LAMS lumen. The patient experienced no adverse postprocedural events, and a follow-up upper gastrointestinal series 6 weeks postprocedure demonstrated no persistent fistula. The novel complication of buried large-diameter LAMS in G-G access during EDGE highlights the technical feasibility of LAMS-in-LAMS rescue for gastric access for temporary endoscopy completion in patients with RYGB and buried LAMS. Leaving a stent for more than 4 weeks increases the risk of a buried stent and persistent G-G fistula.2Figure 1.: LAMS-in-LAMS rescue technique for a buried large-diameter LAMS in a gastric-gastric access during endoscopic EDGE. (A) Buried LAMS in the remnant stomach during stage 2 of EDGE. (B) LAMS-in-LAMS rescue via a noncautery enhanced (cold LAMS) technique. (C) Fluoroscopy showing a successful LAMS-in-LAMS bridge (arrow, new LAMS; arrowhead, buried LAMS) before ERCP. (D) Completion of ERCP by bridging the buried GATE (asterisk, LAMS-in-LAMS bridge). EDGE, endoscopic ultrasound–directed transgastric ERCP; ERCP, endoscopic retrograde cholangiopancreatography; GATE, gastric access for temporary endoscopy; LAMS, lumen apposing metal stent.DISCLOSURES Author contributions: Conception and design: BM Honan, SA Sánchez-Luna, R. Mulki. Acquisition of data: SA Sánchez-Luna, R. Mulki. Drafting manuscript: BM Honan, SA Sánchez-Luna. Critical review: BM Honan, SA Sánchez-Luna, R. Mulki. Supervision: SA Sánchez-Luna, R. Mulki. SA Sánchez-Luna is the article guarantor. Financial disclosure: SA Sánchez-Luna, MD, is the recipient of the 2021 American Society for Gastrointestinal Endoscopy (ASGE) Endoscopic Training Award by the ASGE and Fujifilm. He is also a consultant for Olympus. These were not relevant to this manuscript. The rest of the authors have no conflicts of interest to disclose. We have no grants, financial support, or funding information to disclose. Previous presentation: This case was presented as a poster at Digestive Disease Week 2023 in Chicago, IL, on May 6, 2023. Informed consent was obtained for this case report.