Surgical Endoscopy

, Volume 33, Issue 6, pp 2024–2033 | Cite as

Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients

  • Thomas J. Wang
  • Christopher C. Thompson
  • Marvin RyouEmail author
Dynamic Manuscript



Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is technically challenging. Device-assisted enteroscopy and laparoscopic-assisted methods suffer from high failure rates and/or post-procedural complications. A novel endoscopic technique termed EUS-Directed Transgastric ERCP (EDGE) or Gastric Access Temporary for Endoscopy (GATE) has recently emerged, demonstrating excellent technical and therapeutic success. The technique involves endoscopic ultrasound-guided deployment of a lumen-apposing metal stent (LAMS) to gain access into the remnant stomach to facilitate standard ERCP. In this case series, we describe our center’s experience and unique approach with the GATE procedure and discuss several key strategies and differences.


Patients underwent the GATE procedure via a novel algorithmic approach. Key information on procedural details, technical and clinical success, follow-up, and adverse events was prospectively collected and retrospectively reviewed.


10 patients underwent the GATE procedure from May 2017 to March 2018. Technical and clinical success were both 100%. Gastric and jejunal access points for LAMS deployment were 30% and 70%, respectively. Total procedure time per patient, including LAMS deployment, ERCP, and all follow-up procedures, averaged 2.37 ± 0.63 h. 2 out of 10 patients (20%) had adverse events that were resolved either intra-procedurally or after repeat endoscopy with no long-term complications and none requiring surgery. For patients with complete follow-up (n = 7), access tract closure rate was 100% with the aid of a temporary plastic double pigtail stent to facilitate closure.


GATE appears to be a safe and effective procedure and may be considered the preferred approach to ERCP in patients with RYGB anatomy at centers with LAMS experience. The procedure offers more definitive and higher range of ERCP interventions compared to traditional methods and is associated with fewer adverse events. Improvements in strategies and methods with the GATE technique may reduce risks and improve outcomes.


Roux-en-Y gastric bypass Lumen-apposing metal stent Endoscopic ultrasound-directed transgastric ERCP Gastric access temporary for endoscopy Plastic double pigtail stent 



We would like to thank Dr. Matthew James Skinner for his time in editing and providing voice narration for the video that accompanied this manuscript.

Compliance with ethical standards


Dr. Christopher C. Thompson is a consultant for Boston Scientific and Olympus America Inc. Dr. Marvin Ryou is a consultant for Medtronic, Inc. Dr. Thomas Wang has no conflict of interest or financial ties to disclose.

Supplementary material

Supplementary material 1 (MP4 67660 KB)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Thomas J. Wang
    • 1
    • 3
  • Christopher C. Thompson
    • 2
    • 3
  • Marvin Ryou
    • 2
    • 3
    Email author
  1. 1.Department of MedicineMassachusetts General HospitalBostonUSA
  2. 2.Department of GastroenterologyBrigham and Women’s HospitalBostonUSA
  3. 3.Harvard Medical SchoolBostonUSA

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