S5241 EUS-Directed Transgastric ERCP (EDGE) After Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass (SG-RYGB): Managing Biliary Leak and Stones in Complex Surgically Altered Anatomy

Introduction: In patients with Roux-en-Y gastric bypass (RYGB), conventional endoscopic retrograde cholangiopancreatography (ERCP) is not possible due to altered anatomy. Alternatives include endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE), laparoscopic-assisted ERCP (LA-ERCP), and enteroscopic ERCP. EDGE is a technique that creates a temporary fistula between the gastric pouch and the excluded stomach using a lumen-apposing metal stent (LAMS), allowing conventional ERCP. While EDGE is effective in RYGB cases, its use in patients with a prior sleeve gastrectomy (SG) converted to RYGB (SG-RYGB) is rare due to limited working space in the reduced stomach sections. We present a case of successful EDGE following failed alternative approaches. Case Description: A 64-year-old woman with a history of SG-RYGB for morbid obesity underwent a cholecystectomy for symptomatic cholelithiasis at an external hospital. Due to postoperative cystic duct stump leakage and untreated bile duct stones, LA-ERCP was performed, resulting in the placement of a pancreatic stent (PS) but failed biliary cannulation, prompting her transfer to our surgical center. Exploratory laparotomy with common bile duct (CBD) exploration and partial stone removal was conducted, but bile leakage persisted. Conservative measures, including computed tomography-guided drainage of a bilioma in the former gallbladder bed and antibiotics, were unsuccessful. Therefore, the patient was referred to our interventional endoscopy unit (Department of Gastroenterology), and EDGE was performed. Using a therapeutic linear echoendoscope, the excluded stomach was punctured with a 19-gauge endoscopic ultrasound-guided needle, followed by the injection of contrast media to confirm positioning. Subsequently, sterile water was injected to distend the excluded stomach. A 0.035 in guidewire was advanced, followed by the placement of a 20 mm × 10 mm electrocautery-enhanced LAMS, creating a gastro-gastric fistula. Transgastric ERCP showed large CBD stones, a cystic duct stump leak, and the PS. After biliary sphincterotomy, all stones were extracted, a 10 Fr biliary plastic stent was placed, and the PS was extracted. No complications occurred. After healing of the bile leak, the biliary stent and LAMS were removed. Discussion: This case illustrates the value of EDGE for biliopancreatic interventions in RYGB patients, even after conversion from SG, which increases procedural complexity. In tertiary centers, it should be considered early in post-bariatric patients.