Introduction: Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) is a relatively new technique that creates a transluminal path to the remnant stomach from the gastric pouch or jejunum to manage pancreatic-biliary diseases. However, we modified this technique to perform endoscopic ultrasound-directed transgastric percutaneous gastrostomy (EDGG) tube placement and securing the lumen apposing metal stent (LAMS) with a stentfix OTSC system.
Case Description/Methods: A 51-year-old female with a complicated past medical and surgical history of gastric bypass who had prolonged ICU stay, and severe malnutrition required urgent parenteral nutritional feeds. Due to her extensive and complicated abdominal surgeries, she was considered not a candidate for surgical gastrostomy. Then, the decision was made to place the percutaneous endoscopic jejunostomy (PEJ) tube. However, we could not find a window for PEJ tube placement and elected to proceed with EDGG tube placement. With Linear Echoendoscope, the remnant stomach was punctured with a 19-gauge needle from the gastric pouch. The remnant stomach was filled with normal saline and hot Axios LAMS stent was deployed creating gastro-gastric fistula which got dilated (Fig. 1&2). The feeding tube was inserted using the standard pull-through technique. The internal bumper of the gastrostomy tube could not be traversed through the LAMS. Despite multiple attempts by holding the internal bumper with rat-tooth forceps, still could not traverse and LAMS appeared to be at risk of being dislodged. To avoid complications, we decided to secure LAMS by placing two stentfix OTSC system on either side of LAMS (Fig. 3). The Internal bumper went through the LAMS successfully without dislodging it. Follow-up upper endoscocpy after four weeks reveal the LAMS with stentfix OTSC system at the gastro-gastric fistula that got removed (Fig. 4&5).
Discussion: On performing EDGG tube placement,the internal bumper of the gastrostomy tube couldn’t traverse the LAMS stent despite dilatation which could've led to its migration and perforation which would’ve been lethal. We overcame the situation by placing two stentfix OVESCO system anchoring the LAMS into the gastric pouch allowing the internal bumper to traverse easily. The PEG tube was deemed appropriate for nutritional feed. Therefore, we recommend the use of a stentfix OTSC system as an option to anchor the LAMS during EDGG tube placement procedures and prevent migration of LAMS.
Figure: Endoscopic Images
M Kenan Rahima indicated no relevant financial relationships.
Venkata Muddana indicated no relevant financial relationships.
Mohamad Hijazi indicated no relevant financial relationships.
Cynthia Contreras indicated no relevant financial relationships.
Usha Thapa indicated no relevant financial relationships.
M Kenan Rahima, MD, Venkata Muddana, MD, Mohamad Hijazi, MD, Cynthia Contreras, MD, Usha Thapa, MD. P0883 - Endoscopic Ultrasound-Directed Transgastric Percutaneous Gastrostomy Tube Placement With Stentfix to Metal Stent in Gastric Bypass Patient, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.