Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis

Abstract

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy, which is increasing in frequency given the rise of obesity. Laparoscopy-assisted ERCP (LA-ERCP) and enteroscopy-assisted ERCP (EA-ERCP) are distinct approaches with their respective strengths and weaknesses. We conducted a meta-analysis comparing the procedural time, rates of success and adverse events of each method. Patients and methods A search of PubMed, EMBASE and the Cochrane library was performed from inception to October 2018 for studies reporting outcomes of LA or EA-ERCP in patients with RYGB anatomy. Studies using single, double, ‘short’ double-balloon or spiral enteroscopy were included in the EA-ERCP arm. Outcomes of interest included procedural time, papilla identification, papilla cannulation, therapeutic success and adverse events. Therapeutic success was defined as successful completion of the originally intended diagnostic or therapeutic indication for ERCP. Results A total of 3859 studies were initially identified using our search strategy, of which 26 studies met the inclusion criteria. The pooled rate of therapeutic success was significantly higher in LA-ERCP (97.9 %; 95 % CI: 96.7–98.7 %) with little heterogeneity (I2 = 0.0 %) when compared to EA-ERCP (73.2 %; 95 % CI: 62.5–82.6 %) with significant heterogeneity (I2: 80.2 %). Conversely, the pooled rate of adverse events was significantly higher in LA-ERCP (19.0 %; 95 % CI: 12.6–26.4 %) when compared to EA-ERCP (6.5 %; 95% CI: 3.9–9.6 %). The pooled mean procedure time for LA-ERCP was 158.4 minutes (SD ± 20) which was also higher than the mean pooled procedure time for EA-ERCP at 100.5 minutes (SD ± 19.2). Conclusions LA-ERCP is significantly more effective than EA-ERCP in patients with RYGB but is associated with a higher rate of adverse events and longer procedural time.

Endoscopic biliary therapy in the era of bariatric surgery

“…The main complications of infection and bleeding are attributed to the laparoscopic portion of the procedure. Direct ERCP related complications appeared similar between LAP-ERCP and BE-ERCP (13,16). The most common ERCP related complication is pancreatitis, which is not a risk where the ampulla is not identified and therefore cannulation not attempted (a scenario more commonly seen for BE-ERCP).…”

“…In separate meta-analyses De Ponte Neto (2018) showed a native cannulation rate of 95.7% vs 82.2% for LAP-ERCP vs DBE-ERCP and 95.7% vs 62.2% compared to SBE-ERCP (15). Ayoub (2020) demonstrated a pooled cannulation rate of 97.8% vs 73.0% for LAP-ERCP vs BE-ERCP (16). The LAP-ERCP complication rate was approximately 11% and 12% higher in de Ponte-Neto's and Ayoub's analysis respectively.…”

Laparoscopic assisted ERCP in patient with Roux-en-Y gastric bypass. A case report

“…Bukhari et al [ 15 ] concluded that EDGE is superior to B-ERCP in terms of technical success and shorter procedural time. Ayoub et al [ 16 ] compared laparoscopic assisted ERCP and B-ERCP, underlining the superior effectiveness of the former, considering it as a first-line approach, even though it is associated with longer procedural time and a higher risk of adverse events. Another point to consider, besides effectiveness, is the feasibility of these procedures in all hospitals.…”

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery

“…However, the efficacy of therapeutic interventions via the enteroscopic route is usually limited. [1][2][3] Direct cholangioscopy has emerged as a cornerstone in the evaluation of indeterminate biliary strictures and in the treatment approach for complex biliary stones. [4][5][6] Currently, no cholangioscopy system on the market can be used via the enteroscopic approach.…”

“…However, the efficacy of therapeutic interventions via the enteroscopic route is usually limited. 1 , 2 , 3 …”