B.Joseph Elmunzer, MD, MSc - Case presentation - GI2019

Case presentation
Briana Lewis, MD

B. Joseph Elmunzer, MD, MSc

Case Presentation
This is a 63 year-old woman who presented to an outside hospital with
chief complaint of right upper quadrant abdominal pain radiating to her
back. She also reported anorexia for two days prior to her admission
but denied any fever, chills, nausea, or vomiting . Upon arrival, she was
initially normotensive but later became hemodynamically unstable
requiring vasopressors in the intensive unit. Labs were pertinent for
WBC 12, T. Bili 2.0, and ALP ~ 200s.

         PMH: Diabetes and Morbid Obesity
         PSHx: Cholecystectomy and Roux-en-Y Gastric Bypass

Hospital Course at the OSH
 Found to have Enterococcus bacteremia

 CT Findings: Intrahepatic and extrahepatic biliary dilation with the
  CBD measuring up to 1.3 cm

 Went to IR for cholangiogram and PTC placement

 Transferred to MUSC for ERCP

Hospital Course at MUSC

 Labs: T. Bili 1.7, AST 46, ALT 19, and ALP 256

 IR exchanged her PTC and repeated cholangiogram which did not
  identify a stone.

 MRCP findings: Choledocholithiasis with a stone measuring
  approx. 2.5 cm within the mid common bile duct

 We performed an EUS-directed transgastric ERCP for stone
  removal

EUS-Directed Transgastric ERCP (EDGE)
Creation of gastro-gastric or jejuno-gastric tract via EUS and
                             FNA

          Expand excluded stomach with contrast

     Establish tract with a lumen apposing metal stent

                  Reach excluded stomach

                  Perform standard ERCP

Sphincterotomy
A. PTC drain emerging from the major papilla
B. Sphincterotomy followed by dilation of the major papilla with a 12 mm balloon

Stone Removal
A. Main bile duct with one large stone
B. After biliary tree sweep and stone extraction

Clinical Course after EDGE
She did well after the procedure. Two days later, she underwent EGD for stent removal and
endoscopic closure of her jejuno-gastric fistula.

          A. Axios stent in the gastrostomy tract   B. Defect (later closed with an over the scope clip)

What options for ERCP are available for
patients with altered luminal anatomy
  from a Roux-en-Y gastric bypass?

There are several challenges with performing an ERCP in patients with
altered luminal anatomy from weight loss surgeries. It can be technically
difficult to reach the major papilla due to a long Roux limb (100-200 cm),
angulations, adhesions, internal hernias, and looping.

EUS-Directed Transgastric ERCP (EDGE)

                    Novel procedure

                    The transgastric approach was
                     first introduced by Baron and
                     Vickers in 1998.

                    Highly affective approach with
                     patients with Roux-en-Y gastric
                     bypass anatomy

EUS-Directed Transgastric ERCP (EDGE)

                    Strengths:
                       Can be performed with a
                        single endoscopic team all
                        within one day
                       Technical success rate > 95 %.

                    Limitations:
                       Availability of the procedure
                        (ie tertiary centers).
                       14 % risk of an adverse event
                       Possible weight regain after
                        gastrostomy tract creation

Balloon Assisted ERCP (B-ERCP)

                     Limitations
                        Tangential views of papilla
                        Unstable working platform
                        Absence of device elevator
                        Suboptimal accessory
                         performance due to small
                         diameter of working
                         channel and tortuous
                         nature of the enteroscope

                     Technical success rates have
                      been reported as low as 63%

Intra-Operative ERCP
 A combined surgical (open or
  laparoscopic) and endoscopic
  approach

 The most common laparoscopic
  technique uses three transabdominal
  ports.
    Trocar is in the excluded stomach

 The duodenoscope is introduced
  through the surgically placed trocar.

Intra-Operative ERCP
 Strengths:
   Can use standard ERCP
      accessories
   High success rates

 Limitations:
   Costs
   Surgical Risks
   Coordinating schedules with
     surgeons and interventional
     endoscopists
   If repeat ERCP is needed in the
     future, the patient would require
     a gastrostomy tube

Take Home Points

 Rapid weight loss after gastric bypass is a risk factor for
  developing gallstones which can lead to choledocholithiasis or
  pancreatitis.

 There are challenges in performing an ERCP in patients who have
  an altered luminal anatomy after a weight loss surgery.

 Options for ERCP may include EDGE, balloon assisted ERCP, and
  intraoperative ERCP. Each procedure has its strengths and
  weaknesses that should be evaluated beforehand.

Questions?