Endoscopic ultrasound-directed transenteric ERCP (EDEE) in patients with postsurgical anatomy – novel but challenging

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with postsurgical upper gastrointestinal anatomy and enteroscopy-guided ERCP (e-ERCP) is utilized in most of these patients for biliary access [1]. Procedural success is suboptimal, especially in patients with Roux-en-Y anatomy. In patients with a Roux-en-Y gastric bypass (RYGB), we use EUS-directed transgastric ERCP (EDGE) for access into the excluded stomach and subsequent ERCP using standard duodenoscopes and equipment [2]. Nonetheless, the EDGE procedure remains controversial because of the potential risk of a permanent gastro-gastric fistula. In our experience, this risk is very low but data are needed to confirm the long-term safety of EDGE [2].

In patients with challenging surgical anatomy other than RYGB who fail e-ERCP, the options are limited. Surgical and percutaneous access are feasible but are associated with significant morbidity, the need for repeated interventions, and a negative impact on quality of life. Therefore, an endoscopic option is typically sought at tertiary centers. EUS-guided biliary drainage (EUS-BD) is an attractive procedure and recent advances in the field of interventional EUS have rendered these procedures more widespread, despite their challenging nature and intricacies [3]. A multicenter study, which compared the outcomes of 98 patients with surgical anatomy and biliary obstruction who underwent either e-ERCP or EUS-BD, found that EUS-BD had a higher rate of clinical success (98 % vs. 65.3 %; P = 0.001), albeit this was associated with a higher rate of adverse events (20 % vs. 4 %; P = 0.01) [3]. Based on these results, in patients with surgical anatomy (non-RYGB), we reserve EUS-BD for those who fail e-ERCP.

“EUS-directed transenteric ERCP (EDEE) is an innovative procedure and is a welcome addition to the armamentarium of EUS-guided biliary access procedures.”

EUS-guided hepatogastrostomy (HGS) is most frequently employed in such patients for biliary access. Biliary interventions can be performed through the HGS track during the same session, although most commonly this is done at least 1 – 2 weeks later to allow the track to mature [4] [5]. EUS-HGS and subsequent interventions are very challenging/not possible when the intrahepatics are not significantly dilated. This is not infrequent in patients with benign biliary pathologies. Also, EUS-HGS may not be possible in other instances, such as in patients after total gastrectomy, liver resection, and liver transplantation. In these instances, we revert to EUS-directed transenteric ERCP (EDEE).

We first described EDEE in a post-liver transplant patient with Roux-en-Y anatomy who presented with biliary cast syndrome and had failed multiple e-ERCPs because of extensive biliary casts [6]. During EDEE, a gastroenteric or entero-enteric anastomosis is created between the proximal gastrointestinal tract and the small-bowel loop containing the ampulla/bilioenteric anastomosis using a lumen-apposing stent. This constitutes a short-cut to the biliary tree, which permits easy and efficient ERCP. Importantly, EDEE allows the use of standard ERCP equipment (e. g. for cholangioscopy and lithotripsy) [6].

In the current study, Mutignani and colleagues [7] elegantly present the outcomes of 32 patients with Roux-en-Y reconstruction or who had undergone pancreaticoduodenectomy who underwent EDEE either because of an inability to endoscopically reach the biliary site or because of a high preprocedural probability of needing complex biliary interventions. Creation of an entero-enteric anastomosis was performed using fully covered stents (16-mm diameter and 20-mm saddle length). In the majority of patients (n = 29), a percutaneous transhepatic biliary drain (PTBD) was needed to opacify and distend the small bowel with contrast/fluid for proper targeting with EUS. Technical success of EDEE was achieved in 31 patients (97.5 %) with one episode of moderate self-limited bleeding. ERCP was successfully completed in all patients at a mean of 2.7 days after creation of the entero-enteric anastomosis [7].

Although this study [7] illustrates the feasibility of EDEE, it points to the prerequisite of having access to the afferent loop for injection of contrast/fluid. In the current series, 90 % of patients had PTBDs that were used to facilitate access to the biliary limb. In the remaining few patients, a 7-Fr endoscopic catheter was advanced to the limb and injection of contrast/fluid was accomplished through the catheter. Placement of a PTBD solely for this purpose seems invasive and adds to the overall procedural risk and cost, as well as adding inconvenience for the patient; however, placement of PTBD is required in some cases. In cases where the biliary limb can be reached endoscopically, our preference is to inject contrast and fluid through the therapeutic channel of the endoscope after administration of glucagon to inhibit small-bowel peristalsis. In addition, we add methylene blue to the injectate solution. Once the biliary limb is opacified, the endoscope is swiftly changed to an echoendoscope and the opacified limb is approached under fluoroscopic guidance followed by access using a 19 G fine needle aspiration (“finder”) needle, with aspiration of blue dye confirming that the correct small-bowel limb has been accessed.

Although the stents used in the current study are not true lumen-apposing metal stents (LAMSs), we prefer using an electrocautery tip-enhanced LAMS. This allows direct and easier access to the opacified loop without the need for prior wire advancement, tract dilation, and instrument exchanges. Also, the 10-mm saddle length and lumen-apposing characteristics likely decrease the risks of leakage and migration.

The authors performed the ERCP procedures after a mean of 2.7 days of entero-enteric stent placement [7]. The entero-enteric fistula needs at least 1 – 2 weeks to mature and stent migration during the procedure is equivalent to a perforation. Because most patients in the current study had previous PTBDs in place, our preference would be to wait for fistula maturation before performing ERCP [6]. An alternative method for patients in need of urgent biliary access would be to secure the LAMS to the gastrointestinal tract via endoscopic suturing or placement of an over-the-scope clip [8].

EDEE is an innovative procedure and is a welcome addition to the armamentarium of EUS-guided biliary access procedures. It has been made possible by the widespread use of LAMSs. The procedure remains technically challenging with potentially serious adverse events, such as stent migration and perforation. Refinement of the technique and prospective studies are needed to better define the role of EDEE in the challenging population of patients with surgically altered upper gastrointestinal anatomy who require ERCP.

• References

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• 2 Bukhari M, Kowalski T, Nieto J. et al. An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc 2018; 88: 486-494
• 3 Khashab MA, El Zein MH, Sharzehi K. et al. EUS-guided biliary drainage or enteroscopy-assisted ERCP in patients with surgical anatomy and biliary obstruction: an international comparative study. Endosc Int Open 2016; 4: E1322-E1327
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• 8 Irani S, Yang J, Khashab MA. Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP. VideoGIE 2018; 3: 322-324