EUS-Directed Transgastric ERCP (EDGE) after conversion of sleeve gastrectomy to roux-en-Y gastric bypass (SG-RYGB): managing biliary leak and stones in complex surgically altered anatomy

Introduction: In patients with Roux-en-Y gastric bypass (RYGB), conventional ERCP is not possible due to altered anatomy. Alternatives include EUS-directed transgastric ERCP (EDGE), laparoscopic-assisted ERCP (LA-ERCP), and enteroscopic ERCP (E-ERCP). EDGE is a technique that creates a temporary fistula between the gastric pouch and the excluded stomach using a lumen-apposing metal stent (LAMS), allowing conventional ERCP. While EDGE is effective in RYGB cases, its use in patients with a prior sleeve gastrectomy (SG) converted to RYGB (SG-RYGB) is rare due to limited working space in the reduced stomach sections. We present a case of successful EDGE following failed alternative approaches.