Amy Tyberg, MD, from the Division of Gastroenterology and Hepatology, Weil Cornell Medical College, Cornell University, in New York, New York, USA shares this video case “EUS-directed jejunogastric lumen-apposing metal stent to facilitate cystgastrostomy in a patient with Roux-en-Y anatomy.”

This case describes a 54-year-old man with Roux-en-Y anatomy who presented with a symptomatic pancreatic pseudocyst. An endoscopic-ultrasound (EUS) guided jejuno-gastric fistula with placement of a lumen-apposing metal stent (LAMS) was performed. The pancreatic pseudocyst was then accessed and drained endoscopically by passing an echoendoscope though the jejuno-gastric LAMS and performing a cystgastrostomy with placement of a second LAMS from the bypassed stomach.

Endoscopic drainage is now the preferred management for symptomatic pancreatic fluid collections (PFCs). This technique involves identifying and accessing the PFC using endoscopic ultrasound, creating a fistulous tract, and deploying a drainage stent across the fistulous tract. In patients with Roux-en-Y anatomy, endoscopic drainage of PFCs in the head of the pancreas can be challenging due to the inability to reach the collection with an echoendoscope.

Accessing the bypassed stomach endoscopically has been previously described for ampullary access in patients with altered anatomy requiring endoscopic retrograde cholangiopancreatography (ERCP) using the EDGE technique (EUS-directed transgastric ERCP). This technique involves EUS-guided identification and access of the bypassed stomach from the gastric pouch or small bowel, creation of a fistulous tract, and deployment of a LAMS across the fistulous tract with subsequent passage of a duodenoscope through the LAMS. In this video, we show that the EDGE technique can be successfully performed for additional indications. In this patient, a jejuno-gastric LAMS was placed via the EDGE technique and an echoendoscope was passed through the LAMS into the bypassed stomach to facilitate cystgastrostomy.

By using this technique, the patient was spared a more invasive percutaneous and/or surgical intervention for PFC drainage.

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