Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study

Abstract

Background and Study Aims: Endoscopic ultrasound-directed transgastric ERCP (EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. Aims of this study were 1) to determine rates of long-term adverse events (AEs) after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; 2) identify predictors of persistent fistula; 3) assess outcomes of endoscopic closure when persistent fistula is encountered. Patients and Methods: This was a multicenter, retrospective study involving 13 centers between 1/2014 and 3/2019. AEs were defined according to ASGE lexicon. Persistent fistula was defined as upper GI series or EGD showing evidence of fistula. Results: A total of 178 patients (mean age 58 years, 79% F) underwent EDGE. Technical success was achieved in 98% of cases (175/178) with a mean procedure time of 92 min. Periprocedural AEs occurred in 28 patients (15.7%; mild 10.1%, moderate 3.3%, severe 2.2%). The 4 severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10% of those sent for objective testing (9/90). Following identification of fistula, 5/9 patients underwent endoscopic closure procedures, which were successful in all cases. Conclusions: The EDGE procedure is associated with high clinical success rates, and an acceptable risk profile. Persistent fistula after lumen apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistula are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.

Biliopancreatic Endoscopy in Altered Anatomy

“…The technique contemplates the use of either over-the-wire (OTW) LAMS placement or the freehand technique to release LAMS, depending on expertise and availability of the centers. The studies about EDGE reported an extremely high success rate of this novel technique, between 96.5 and 100% [ 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ]. Adverse events include mostly LAMS maldeployment and migration, which seemed to be mainly seen in those studies in which authors used the OTW technique.…”

Endoscopic retrograde cholangiopancreatography: Current practice and future research

“…Importantly, the procedure has gained popularity since 2015[ 46 ] because of the ability to use conventional cannulation techniques and equipment. A retrospective multicenter review[ 47 ] of 178 patients reported a technical success of 98% (175/178) countered by 4 severe adverse events (SAE) (2.2%) and 10% of patients having a documented persistent fistula (9/90). It has been proposed that the EDGE could be used in patients with a RYGB, of which the details like limb length are unknown, and in patients with a surgically absent gallbladder[ 48 ].…”

Endoscopic ultrasound-guided biliary drainage: Are we there yet?

“…In 2017, a multicenter study on 16 patients undergoing EDGE procedure reported a high technical (100%) and clinical (91%) success, with stent dislodgement occurring in 19% patients[ 87 ]. A recent multicenter retrospective study by Runge et al [ 88 ] reported long-term outcomes in 178 patients following EDGE procedure[ 88 ]. Technical success was achieved in 98% cases with adverse events occurring in 28 (15.7%) patients.…”

“…Persistent fistula between the gastric remnant and excluded stomach and subsequent weight gain is a worrisome complication of the EDGE procedure. However, most major studies have not shown any significant weight gain associated with the procedure[ 88 - 90 ]. Given the reported safety profile and high success rate of the EDGE procedure, it can be used as a first line therapy in RYGB patients requiring biliary interventions.…”