Post written by Giuseppe Vanella, MD, from the Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Institute, Milan, Italy.

In the realm of endoscopy, the advent of lumen-apposing metal stents (LAMSs) has paved the way for innovative solutions to challenges once considered insurmountable. One such breakthrough is the technique known as EUS-directed transgastric ERCP (EDGE), which offers a minimally invasive approach to restore access to the papillary region in patients with a history of Roux-en-Y gastric bypass for obesity.

The EDGE procedure involves locating the remnant stomach through the gastric pouch, providing a pathway to reach the antrum and duodenum. However, its application becomes even more intricate in cases of complex surgical reconstructions, such as Roux-en-Y gastric bypass after a sleeve gastrectomy. In these instances, the remnant stomach, typically smaller, is displaced toward the liver and accessible through the postanastomotic jejunum.

We present a compelling case involving a 30-year-old woman admitted for symptomatic choledocholithiasis who presented with such a complex anatomy. The patient was successfully treated using the EDGE technique, enabling subsequent ERCP, stone extraction, and even diagnostic EUS before LAMS removal to let the fistula heal avoiding weight regain.

The video highlights the step-by-step process of locating the gastric remnant through precise EUS examination before the sequence of puncturing, distending, and releasing the LAMS. This emphasizes the feasibility of EDGE even in challenging postsurgical anatomies.

Given the increasing prevalence of complex postsurgical anatomies, particularly in the field of bariatric endoscopy, addressing pancreatobiliary events in such patients is no small feat. EDGE emerges as a more straightforward alternative to enteroscopy-assisted ERCP and a less-invasive option than traditional surgical approaches.

Key takeaways from this case include the significance of meticulous endosonographic study, navigation from the postanastomotic jejunum, and the proven feasibility of EDGE in scenarios involving a smaller and dislocated gastric remnant. We hope this video might serve as a valuable learning resource to inspire confidence among other endoscopists when navigating these complex anatomies while underscoring the importance of managing these patients in tertiary referral centers with expertise in therapeutic EUS.

While showcasing the potential of EDGE in managing pancreatobiliary events after bariatric surgery, this video case also points out the importance of adapting techniques to meet the unique challenges that changing surgical landscapes pose.

Through-the-LAMS ERCP. The patient was readmitted after 2 weeks to undergo elective through-the-LAMS ERCP. The LAMS was anchored via 2 endoclips. The jejunal loop was intubated with a standard duodenoscope, and the LAMS was traversed under endoscopic visualization (A) and fluoroscopic control (B). The pylorus was located just downstream of the LAMS (A). LAMS, Lumen-apposing metal stent.

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