A Novel Application of a Through the Scope Fully Covered Esophageal Stent for an Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography Procedure

Performing traditional endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass anatomy is challenging. The endoscopic ultrasound-directed transgastric ERCP (EDGE) procedure offers a minimally invasive solution. This case describes a 53-year-old woman with a history of Roux-en-Y gastric bypass presenting with cholelithiasis, abnormal liver function tests, and cholecystitis. After initial conservative treatment, a staged EDGE procedure was performed. A lumen-apposing metal stent (LAMS) was placed in the jejunum, but subsequent attempts to cannulate it with the ERCP scope were unsuccessful due to "bowing" of the efferent loop. A fully covered esophageal stent was placed through the LAMS creating a "ramp" allowing passage of the duodenoscope, enabling successful ERCP and stone removal. This case highlights an effective technique to overcome often encountered challenges accessing LAMS during an EDGE procedure.