Introduction:
Patients with concomitant gastric outlet obstruction from benign or malignant causes and associated biliary obstruction have limited management options. The EDGE procedure (endoscopic ultrasound directed transgastric endoscopic retrograde cholangiopancreatography) has been well documented in patients with surgically altered anatomy as a means of allowing access to the 2^nd portion of the duodenum in patients with surgically altered gastric anatomy. While endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) has been used in treatment of both benign and malignant gastric outlet obstruction, its use for ERCP (endoscopic retrograde cholangiopancreatography) through the lumen apposing stent (LAMS) has not been reported. We detail the institutional experience with nine patients who underwent ERCP through EUS-GJ, an approach not yet described in the literature.

Methods:
This is a retrospective observational study from the years 2018 – 2023 at a tertiary referral center. A total of nine patients were selected based on a history of concomitant gastric outlet obstruction and biliary obstruction treated with EUS-GJ and ERCP through the EUS-GJ itself for access. Each of the patients selected was previously evaluated and deemed not to be a candidate for surgical treatment.

Results:
Patients were 22.2% female, had an average BMI of 22.07, and had an average age of 75.8 years (Table 1). There was 100% technical success and there were no reported complications over the study period. The endoscope used for ERCP through the LAMS was a duodenoscope in 3 patients and a therapeutic esophagogastroduodenoscopy (EGD) scope in 6 of 9 patients. The underlying pancreaticobiliary pathology was malignancy in 5 patients, chronic pancreatitis in 3 patients, non-malignant biliary stricture in 1 patient (Table 2). The underlying gastric outlet pathology was malignancy in 5 patients, chronic pancreatitis in 3 patients, and non-malignant duodenal stricture in 1 patient (Table 2).

Discussion:
This case-series demonstrates excellent clinical outcomes with 100% technical success and no complications from ERCP through EUS-GJ. Both a therapeutic EGD scope and a therapeutic duodenoscope were each able to traverse the fully dilated 20 x 10 mm LAMS (Image 1). Each of the nine patients studied were not surgical candidates due to several factors including metastatic malignancy, active alcohol use, and severe debility.

Flouroscopic image of ERCP performed through endoscopic ultrasound-guided gastrojejunostomy lumen apposing stent.

Subhash Garikipati

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