Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure

Abstract

Background/AimsPerforming endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Rouxen-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS.MethodsAll patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection.ResultsSixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg.ConclusionsEDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

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

“…Recently, EUS-directed transgastric ERCP (EDGE) has emerged as an option for ERCP after RYGB. [10,[13][14][15][16] This technique involves creation of a temporary transgastric fistula by placing a lumen-apposing metal stent (LAMS) connecting either the gastric pouch, or the proximal jejunum, to the excluded stomach (Figure 1). The LAMS creates a stable connection to the excluded stomach, facilitating antegrade ERCP across the new tract.…”

“…Advantages of EDGE include high success rate [10,14], avoidance of surgery, and procedure completion entirely within the endoscopy suite, potentially reducing hospital length-of-stay…”

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“…While available data suggest a high-rate of technical success and low risk of adverse events, this technique has limitations [11]. The most widely accepted iteration of this technique also involves 2 steps, as stent dislodgement into the peritoneum using adult duodenoscopes has occurred when same-day ERC is attempted after creation of the EUSguided gastrogastric or jejunogastric anastomoses [12]. Additionally, following stent removal these translumenal anastomoses may remain patent following management of bile duct stones, and lead to weight regain due to failed spontaneous closure of the gastrogastrostomy.…”

Interventional endoscopic ultrasonography in patients with surgically altered anatomy: Techniques and literature review

“…It may be possible to apply this technique to other altered anatomies by creating the fistula between the remnant stomach or the jejunum and the afferent limb. Recent published data showed a technical success rate of 100% and a clinical success of 90% in 16 patients …”

“…Recent published data showed a technical success rate of 100% and a clinical success of 90% in 16 patients. 47,48…”