Post written by Seifeldin Hakim, MD, and Phillip S. Ge, MD, from the Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Patients with Roux-en-Y gastric bypass (RYGB) anatomy face unique technical challenges in the management of pancreaticobiliary malignancy. EUS-guided RYGB reversal (known as EDGE or GATE procedure) using a lumen-apposing metal stent (LAMS) has gained popularity as a method for gaining temporary access into the bypassed foregut in order to facilitate standard EUS/ERCP.
Our case involved a patient who had a prior sleeve gastrectomy converted to RYGB for morbid obesity, who presented with locally advanced pancreatic ductal adenocarcinoma. During multidisciplinary discussion, permanent endoscopic RYGB reversal was proposed, in anticipation of progressive decline in nutritional status due to bariatric surgery compounded by pancreatic malignancy.
We presented this case in order to highlight the utility of a permanent endoscopic RYGB reversal in the setting of pancreaticobiliary malignancy. The video discusses the technical aspects of EUS-guided RYGB reversal, as well as multiple subsequent procedures that were able to be successfully performed across the access tract. We highlighted various adverse events that are known to occur with the EDGE procedure, including LAMS misdeployment and LAMS dislodgement.
It was important to showcase this video for multiple reasons. From a technical standpoint, we demonstrated the utility of leaving behind a temporary guidewire during every endoscope exchange, in order to preserve the access tract in case the LAMS were to be dislodged during endoscope exchange. We also discussed the inherent instability of having a jejuno-gastric access tract.
EUS-guided RYGB reversal has always been intended to be temporary, with expectation of closure after completion of the necessary intervention, due to risk of unintended reversal of the metabolic effects of bariatric surgery. We presented this case in order to demonstrate the potential value of having a permanent RYGB reversal in patients with pancreaticobiliary malignancy.
Our patient’s permanent RYGB reversal has facilitated multiple endoscopic interventions over the past year, which included:
- Initial EUS/FNA for diagnosis of pancreatic adenocarcinoma.
- Initial ERCP for placement of a fully covered self-expanding metal biliary stent.
- Subsequent EUS-guided fiducial placement in preparation for radiation therapy.
- Subsequent ERCP for replacement of a migrated metal biliary stent.
- Improved nutrition and oral intake while undergoing chemotherapy and radiation therapy for treatment of pancreatic ductal adenocarcinoma.
There are several learning points here. From a technical standpoint, always consider leaving behind a guidewire during any endoscope exchange across a LAMS. This simple step will spare a substantial amount of headache and anxiety should the LAMS become dislodged during endoscope exchange. From a clinical standpoint, for patients with a history of RYGB who present with pancreaticobiliary malignancy, the possibility of permanent endoscopic RYGB reversal should be discussed in a multidisciplinary setting, given the potential advantages in facilitating multiple downstream endoscopic procedures as well as helping to maintain and optimize the patient’s nutritional status during cancer therapy. We hope you find this video to be educational and of benefit to your patients.
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