To perform ERCP and CBD stone clearance in a patient with severe cholangitis in presence of surgically altered anatomy in the form of Roux-en-Y gastric bypass who was deemed very high risk for any other surgical procedure and needed urgent biliary decompression with time as an important limiting factor

The excluded stomach was located endosonographically with a linear echoendoscope from the remnant gastric pouch and then accessed with a 19G EUS needle. Diluted Contrast agent was injected through the 19G needle to insufflate the excluded stomach. A Hot LAMS (Axios; Boston Scientific) was then deployed with the distal end in the excluded stomach and the proximal flange into the remnant gastric pouch. Over a guidewire, the lumen of the stent was then dilated with a CRE balloon. This allowed for the antegrade passage of a duodenoscope through the LAMS into the stomach remnant and to the ampulla, where ERCP was performed successfully. Once ampullary access was no longer required, the LAMS was removed. On follow up visit, the fistula was closed using novel X-Tack™ Endoscopic Helix Tacking System in view of excess weight gain

Both technical success & clinical success (defined as successful ERCP with completion of the intended intervention) was achieved with successful closure of fistulous defect with novel endoscopic closure technique

The EDGE procedure is an entirely endoscopic, highly efficacious, single time procedure for performing ERCP in RYGB patients who require pancreaticobiliary interventions and is associated with high clinical success rates and safety profiles. Large residual defects could be successfully closed by novel X-Tack™ Endoscopic Helix Tacking System