Pancreatic Mass Requiring a Modified Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE) Procedure for Endoscopic Ultrasound (EUS) Evaluation.

Pancreatic cancer is established as being a leading cause of cancer-related mortality within the U.S. annually. Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) has been shown to be more sensitive and specific when compared to computed tomography (CT) imaging for the evaluation of pancreatic masses. Patients with altered anatomy after a Roux-en-Y gastric bypass (RYGB) procedure necessitated the development of additional techniques for biopsy and evaluation of gastrointestinal structures, such as the endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedure. The ERCP procedure was enhanced with the internal EDGE, utilizing the lumen-apposing covered metal stent (LAMS) to create a gastrogastric fistula for instrumentation to pass through in order to access the excluded gastric region without any transcutaneous hardware. The case detailed here required the utilization of a modified EDGE procedure to allow for EUS-FNA of a pancreatic mass in a patient with RYBG anatomy. This is a presentation of a modified internal EDGE procedure in a 70-year-old male with a past medical history of RYGB and colon cancer and presented with a large pancreatic mass that was unable to be sampled by a transcutaneous CT-guided biopsy or EUS alone due to his altered anatomy. Due to the RYGB anatomy of the patient, a modified internal EDGE procedure was conducted in two stages with a LAMS, followed by a transgastric EUS-FNA of the pancreatic mass after access to the isolated gastric limb was achieved. A definitive diagnosis of pancreatic adenocarcinoma was then able to be made based on this biopsy. The benefits of using EUS for pancreatic cancer evaluation are well-established in the literature with a sensitivity of 85-92% and specificity of 96-98% when evaluating pancreatic cancers and using FNA. The pairing of this imaging modality with biopsy capability is what ultimately allowed for a viable sample to be obtained in this case. Due to the limited available literature documenting the utility of an EDGE procedure in obtaining viable samples for oncologic evaluation, this case is a valuable addition as it demonstrates the utility of EDGE with EUS-FNA for difficult biopsy sites related to post-Roux-en-Y anatomy where more conventional measures failed. The authors believe education on the utility of EDGE procedures should be promoted and offered when appropriate and available.