Post written by Hafiz Muzaffar Akbar Khan, MD, from the Division of Gastroenterology and Azhar Hussain, MBBS, from the Division of Medicine, State University of New York Upstate Medical University, Syracuse, New York, USA.

The aim of our study was to evaluate and describe safe and effective use of a through-the-scope endoscopic suturing system for anchoring lumen-apposing metal stents (LAMSs) during single-session EUS-directed transgastric ERCP (SS-EDGE).

During the global obesity pandemic, clinical scenarios requiring urgent ERCP in patients with gastric bypass surgery are on the rise. SS-EDGE can address this situation, but inadequate fixation of the LAMS can result in LAMS dislodgement, especially in the setting of Roux-en-Y gastric bypass with a fixed and narrow excluded stomach, where maneuvering of the duodenoscope can be technically challenging with significant tractional, rotational, and linear forces during ERCP.

In this pilot study, we report a series of 6 consecutive patients who underwent SS-EDGE with successful anchoring of LAMSs using a through-the-scope endoscopic suturing system to prevent stent dislodgement.

Clinical and technical success was achieved in all 6 patients without adverse events related to the procedure. No stent migration, pneumoperitoneum, or GI perforation was noted. Upon 4-week follow-up, no stent migration was documented with the through-the-scope suturing system (X-Tack 160-H; Apollo Endosurgery, Austin, Tex, USA) remaining anchored. LAMSs along with tacks were removed, and gastric fistulae were successfully closed endoscopically in all patients to prevent weight gain.

Therefore, we conclude that use of through-the-scope endoscopic suturing can be a safe, reliable, easy, and potentially cost-effective novel technique for LAMS fixation to successfully perform SS-EDGE in Roux-en-Y gastric bypass patients.

To our knowledge, it is the largest case series on LAMS fixation via a through-the-scope endoscopic suturing system. However, this is a very limited experience and needs more data for the technique to be widely endorsed and adopted.

Multicentric prospective studies and randomized controlled trials with a larger sample size would be helpful in providing more data on the through-the-scope endoscopic suturing system’s safety and efficacy in LAMS fixation in SS-EDGE.

Endoscopic image of a lumen-apposing metal stent anchored with a through-the-scope endoscopic suturing system during single-session EUS-directed transgastric ERCP.

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