Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration

Shinn, Brianna; Boortalary, Tina; Raijman, Isaac; Nieto, José; Khara, Harshit S.; Kumar, Subodh; Confer, Bradley; Diehl, David L.; Halabi, Maan El; Ichkhanian, Yervant; Runge, Thomas M.; Kumbhari, Vivek; Khashab, Mouen A.; Tyberg, Amy; Shahid, Haroon; Sarkar, Avik; Gaidhane, Monica; Bareket, Romy; Kahaleh, Michel; Piraka, Cyrus; Zuchelli, Tobias; Law, Ryan; Sondhi, Arjun; Kedia, Prashant; Robbins, Justin; Calogero, Cristina; Bakhit, Mena; Chiang, Austin L.; Schlachterman, Alexander; Kowalski, Thomas E.; Loren, David E.

doi:10.1016/j.gie.2021.04.022

Cited by 31 publications

(31 citation statements)

References 13 publications

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“…The main drawback is the necessity of a two-session approach to allow the maturation and stabilization of the anastomosis [ 99 , 109 ]. Nevertheless, the technical obstacles during EDGE could be resolved with the application of larger LAMS to inhibit dislodgement and achieve single session interventions [ 110 ] For example, the risk of stent migration using 15 mm LAMS was significantly greater compared to 20 mm stents (odds ratio: 5.36; 95%CI: 1.29–22.24; p ≤ 0.021). Moreover, stent fixation could, also, be a potential alternative, although further evaluation of this hypothesis is necessary [ 110 ] The background of this rationale is based on the mechanical stabilization of the LAMS, as suggested for esophageal stents [ 111 ].…”

Section: Discussionmentioning

confidence: 99%

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

Gkolfakis

Papaefthymiou

Facciorusso

et al. 2022

Life

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Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP. Methods: A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs). Results: Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3–89.4); I2: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4–99.4; I2: 0%) and 99.1% (95%CI: 98.6–99.7; I2: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3–78.0; I2: 86.9%) and 69.1% (95%CI: 65.3–72.9; I2: 91.8%) after EA-ERCP, 98% (95%CI: 96.5–99.6; I2: 0%) and 97.9% (95%CI: 96.3–99.4) after EDGE, and 98.6% (95%CI: 97.9–99.2; I2: 0%) and 98.5% (95%CI: 97.8–99.2; I2: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40–20.8); I2: 87.1%], and EDGE [13.1% (95%CI: 7.50–18.8); I2: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50–6.80); p ≤ 0.04; I2: 64.2%]. Conclusions: LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events.

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Section: Discussionmentioning

confidence: 99%

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

Gkolfakis

Papaefthymiou

Facciorusso

et al. 2022

Life

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“…As demonstrated in this case, same-session EUS and/or ERCP can be safely undertaken provided the stent is adequately secured, thus minimizing the risk of intraprocedural LAMS dislodgment before the tract matures. 4,5 Although our case was ultimately found to have benign pathology, EUS-directed choledochoduodenostomy remains within Whipple resection margins and thus is a valid option for treatment of malignant distal biliary obstruction even in surgically resectable patients. 6 Finally, EUS-guided gastrointestinal anastomoses can be effectively closed endoscopically, and the risk of persistent fistula formation is low.…”

Section: Discussionmentioning

confidence: 80%

Double edged: a dual EUS-guided approach to pancreatobiliary intervention in altered anatomy

et al. 2022

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“…Because the 15mm stents were the only stents used before the introduction of the 20-mm stents in the latter half of 2018 and to account for the learning curve, we compared the overall AE rate in the 15mm stent group before and after the availability of the 20-mm stents and did not find a significant difference (44 % vs 80 %, P = 0.3). Similarly, a recent US multicenter study found a higher intraprocedural stent migration rate with 15-mm LAMS compared to 20-mm LAMS in single-stage EDGE [17]. Those researchers also suggested that LAMS dilation and fixation following deployment could also decrease the LAMS migration rate.…”

Section: E465mentioning

confidence: 88%

Comparison of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography outcomes using various technical approaches

et al. 2022

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Background and study aims Roux-en-Y gastric bypass presents an anatomic challenge for patients needing ERCP. EUS-directed transgastric ERCP (EDGE) offers high clinical success but carries considerable risk of adverse events (AEs) with no standardized technical approach. In our study, we review the safety and efficacy of our various EDGE technical approaches. Patients and methods A retrospective single-center study of all patients who underwent EDGE procedures between February 2018 and November 2019. Primary outcomes included comparing the technical and clinical success, AEs, and lumen-apposing metal stent (LAMS) migration rates per access route (gastrogastric vs jejuno-gastric), number of procedure stages (single-stage vs two-stage), and stent size (15 mm vs 20 mm). Secondary outcomes included LAMS migration characteristics and management. Results Thirty-two EDGE procedures were performed in 29 patients, including 17 single-stage and 15 two-stage procedures, 23 gastrogastric, and nine jejuno-gastric routes, fourteen 15-mm and 17 20-mm LAMS. Overall technical and clinical success rates were 96.9 % and 87.1 %, respectively, without any significant difference between groups. The overall AE rate was (34.4 %) and was significantly lower in the 20-mm LAMS group compared to the 15-mm group (17.6 % vs 57.1 %, P = 0.03). Compared to two-stage procedures, there was no significant difference in AEs with single-stage procedures (35.3 % vs 33.3 %, P = 0.33). The LAMS migration rate was (25 %) with no significant difference between groups. Most migrations were around the index procedure and managed endoscopically (62.5 %). Conclusions EDGE offers high clinical success rates but AE rates remain significant. In our series, a 20-mm LAMS resulted in a significantly lower AE rate than the 15-mm LAMS. Large multicenter studies are recommended to identify technical factors leading to an optimal EDGE procedure.

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Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration

Cited by 31 publications

References 13 publications

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

Double edged: a dual EUS-guided approach to pancreatobiliary intervention in altered anatomy

Comparison of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography outcomes using various technical approaches

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