ENDOSCOPIC ULTRASOUND DIRECTED TRANSDUODENAL ERCP (EDDE) IN A PATIENT WITH A DUODENAL SWITCH FOR COMPLEX STONE MANAGEMENT

Background: Symptomatic gastro-jejunal anastomosis (GJA) strictures occur in 20-30% % of patients with roux-n-y gastric bypass (RYGB).Amongst these, 85% will require endoscopic therapeutic intervention.Balloon dilatation is the most commonly used first-line treatment, but has a low response rate of 22-40 %.Endoscopic therapy for patients that do not respond to BD includes intralesional steroid injection, incisional therapy and placement of a lumen apposing metal stent (LAMS).Approximately 40 % of patients fail endoscopic therapy and require revisional surgery.We describe a novel endoscopic technique, that results in complete remodeling and extension of the GJ anastomosis using two simultaneously placed LAMS's followed by septotomy.Case presentation: 56 y/o female, history of RYGB and multiple comorbidities, referred for endoscopic management of a symptomatic GJA stricture.The patient had stricture recurrence despite BD and placement of a 20 mm * 10 mm LAMS.After a multi-disciplinary discussion, given the patient's poor surgical candidacy, it was decided to proceed with an attempt at definitive endoscopic remodeling.Endoscopic Methods: The GJA was remodeled over the following staged procedures: In the first step of the procedure, a 20 mm 10 mm LAMS was placed over a guidewire through the native GJA.Subsequently, a second 20 mm 10 mm LAMS was placed transmurally via endoscopic ultrasound (EUS) from the gastric pouch into the afferent limb, creating a 2-3 cm tissue bridge between the stents.6 months later, in the second step of the procedure, both LAMS's were removed, and the tissue bridge was reassessed via EUS to exclude large vessels.A soft tip angled guidewire was then passed through the native GJ anastomosis and withdrawn from the newly created GJ fistula to create a loop.The loop was used for tissue traction and to guide the plain of dissection.Using the scissor type and insulated-tip knife, the tissue bridge was dissected completely, thereby creating a de-novo GJ anastomosis meassuring approxiatly 3 cm.No significant bleeding was encountered.After completion, water soluble contrast was injected into the gastric pouch and flowed into the afferent limb with no extravasation.The patient was admitted overnight for observation and started on a liquid diet for 1 week.No adverse events were encountered.Conclusion: This first-in-human case demonstrates the feasibility of a novel technique involving septotomy of a tissue bridge between two closely placed LAMS's to remodel and significantly widen a strictured GJA.This approach offers a viable and less invasive alternative for patients with refractory disease, who would otherwise require a highly morbid operation.