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A 49-year-old woman who had previously undergone Roux-en-Y gastric bypass (RYGB) presented to an outside hospital with cholangitis. Because her RYGB anatomy precluded conventional ERCP, the outside hospital team achieved biliary access by means of EUS-directed transgastric ERCP (EDGE). ERCP with plastic biliary stent placement was completed successfully. During the procedure, the lumen-apposing metal stent (LAMS) that was used to create the gastrogastric fistula (GGF) became dislodged. The GGF was salvaged by placement of a fully covered esophageal stent, which was anchored into place with a full-thickness clip and 4 double-pigtail stents. She presented to our institution 10 months later after gaining 20 pounds because of the reversal of her bypass. To restore her bypass, we planned to repeat the ERCP to remove all transluminal stents and finally to close the GGF with endoscopic suturing (Video 1, available online at www.VideoGIE.org). The

Closure of an iatrogenic gastrogastric fistula created during EUS-directed transgastric ERCP