Same-session EUS-directed transgastric interventions: from tissue acquisition to choledochoduodenostomy

Endoscopic treatment of biliopancreatic diseases in patients with altered anatomy is still challenging, and EUSdirected transgastric intervention (EDGI) represents a valid option for patients with altered anatomy, especially for those who have undergone bariatric surgery. EDGI consists of recreating a connection between the gastric pouch and the excluded stomach using a lumen-apposing metal stent (LAMS) to reach the pancreatobiliary area.1 Then, through the LAMS, a broad range of diagnostic and therapeutic endoscopic procedures can be performed, including ERCP (EUSdirected transgastric ERCP [EDGE]). Although the feasibility and the efficacy of EDGI has been demonstrated,2 it is still unclear how to optimize the technical efficacy and increase the safety of this challenging procedure. Above all, whether all the procedures should be done in 2 different sessions or during the same one is still an object of debate because of the risk of LAMS migration. To date, there are several reports about the same-session EDGE procedure, at least using fixing devices. However, few data are available regarding same-session EUS-guided interventional procedures, which may have the advantage of using the echoendoscope for the entire procedure and avoiding multiple passages through the LAMS. Here we describe a case of same-session EDGI procedures that include an EUS-guided tissue acquisition and biliary drainage