CC BY-NC-ND 4.0 · Endosc Int Open 2020; 08(03): E423-E436
DOI: 10.1055/a-1070-9132
Original article
Owner and Copyright © Georg Thieme Verlag KG 2020

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

Fares Ayoub
1   Section of Gastroenterology, Hepatology & Nutrition, University of Chicago, Illinois, United States
,
Tony S. Brar
2   Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
,
Debdeep Banerjee
3   Department of Medicine, University of Florida, Gainesville, Florida, United States
,
Ali M. Abbas
4   Brigham and Women's Hospital, Division of Gastroenterology, Harvard Medical School, Boston, Massachusetts, United States
,
Yu Wang
5   Department of Biostatistics, University of Florida, Gainesville, Florida, United States
,
Dennis Yang
2   Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
,
Peter V. Draganov
2   Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
› Author Affiliations
Further Information

Publication History

submitted 10 July 2019

accepted after revision 30 October 2019

Publication Date:
21 February 2020 (online)

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.

Supplementary material

 
  • References

  • 1 Stevens GA, Singh GM, Lu Y. et al. National, regional, and global trends in adult overweight and obesity prevalences. Popul Health Metr 2012; 10: 22
  • 2 Nudel J, Sanchez VM. Surgical management of obesity. Metabolism 2019; 92: 206-216
  • 3 Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients – what have we learned?. Obes Surg 2000; 10: 509-513
  • 4 Shuster D, Elmunzer BJ. What is the preferred approach to performing endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y gastric bypass anatomy?. Gastroenterology 2014; 146: 1123-1125
  • 5 Frederiksen NA, Tveskov L, Helgstrand F. et al. Treatment of Common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg 2017; 27: 1409-1413
  • 6 Schreiner MA, Chang L, Gluck M. et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post–Roux-en-Y gastric bypass patients. Gastrointest Endosc 2012; 75: 748-756
  • 7 Doshi B, Yasuda I, Ryozawa S. et al. Current endoscopic strategies for managing large bile duct stones. Dig Endosc 2018; 30: 59-66
  • 8 Abbas AM, Strong AT, Diehl DL. et al. Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Gastrointest Endosc 2018; 87: 1031-1039
  • 9 Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: Case series and a description of technique. Surg Endosc 2011; 25: 2592-2596
  • 10 Ali MF, Modayil R, Gurram KC. et al. Spiral enteroscopy–assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc 2018; 87: 1241-1247
  • 11 Abu Dayyeh B. Single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy: getting there. Gastrointest Endosc 2015; 82: 20-23
  • 12 Wells GA, Shea B, Connell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hosp Res Inst 2000; 2-4
  • 13 Nyaga VN, Arbyn M, Aerts M. Metaprop: A Stata command to perform meta-analysis of binomial data. Arch Public Heal 2014; 72: 1-10
  • 14 Bowman E, Greenberg J, Garren M. et al. Laparoscopic-assisted ERCP and EUS in patients with prior Roux-en-Y gastric bypass surgery: a dual-center case series experience. Surg Endosc 2016; 30: 4647-4652
  • 15 De Koning M, Moreels TG. Comparison of double-balloon and single-balloon enteroscope for therapeutic endoscopic retrograde cholangiography after Roux-en-Y small bowel surgery. BMC Gastroenterol 2016; 16: 98
  • 16 Emmett DS, Mallat DB. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series. Gastrointest Endosc 2007; 66: 1038-1041
  • 17 Falcão M, Campos JM, Neto MG. et al. Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity. Obes Surg 2012; 22: 872-876
  • 18 Grimes KL, Maciel VH, Mata W. et al. Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc 2015; 29: 1753-1759
  • 19 Gutierrez JM, Lederer H, Krook JC. et al. Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass. J Gastrointest Surg 2009; 13: 2170-2175
  • 20 Itokawa F, Ishii K, Tanaka R. et al. Large balloon dilatation following endoscopic sphincterotomy using a balloon enteroscope for the bile duct stone extractions in patients with Roux-en-Y anastomosis. Dig Liver Dis 2011; 43: 237-241
  • 21 Kashani A, Abboud G, Lo SK. et al. Double balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in Roux-en-Y gastric bypass anatomy: expert vs. novice experience. Endosc Int open 2018; 6: E885-E891
  • 22 Lim CH, Jahansouz C, Freeman ML. et al. Outcomes of endoscopic retrograde cholangiopancreatography (ercp) and sphincterotomy for suspected sphincter of Oddi dysfunction (SOD) post Roux-en-Y gastric bypass. Obes Surg 2017; 27: 2656-2662
  • 23 Lopes TL, Clements RH, Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc 2009; 70: 1254-1259
  • 24 Paranandi B, Joshi D, Mohammadi B. et al. Laparoscopy-assisted ERCP (LA-ERCP) following bariatric gastric bypass surgery: Initial experience of a single UK centre. Frontline Gastroenterol 2016; 7: 54-59
  • 25 Petersen B, Saleem A, Levy M. et al. Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy. Endoscopy 2010; 42: 656-660
  • 26 Saleem A, Levy MJ, Petersen BT. et al. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 2012; 16: 203-208
  • 27 Shah RJ, Smolkin M, Yen R. et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013; 77: 593-600
  • 28 Siddiqui AA, Chaaya A, Shelton C. et al. Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study. Dig Dis Sci 2013; 58: 858-864
  • 29 Snauwaert C, Laukens P, Dillemans B. et al. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients. Endosc Int Open 2015; 3: E458-E463
  • 30 Trindade A, Mella J, Slattery E. et al. Use of a cap in single-balloon enteroscopy-assisted endoscopic retrograde cholangiography. Endoscopy 2014; 47: 453-456
  • 31 Habenicht YanceyK, McCormack LK, McNatt SS. et al. Laparoscopic-assisted transgastric ERCP: a single-institution experience. J Obes 2018; 2018: 8275965
  • 32 Choi EK, Chiorean MV, Coté GA. et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013; 27: 2894-2899
  • 33 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
  • 34 Kedia P, Tarnasky PR, Nieto J. et al. EUS-directed transgastric ERCP (EDGE) versus laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y gastric bypass (RYGB) anatomy. J Clin Gastroenterol 2019; 53: 304-308
  • 35 Aiolfi A, Asti E, Rausa E. et al. Trans-gastric ERCP after Roux-en-Y gastric bypass: systematic review and meta-analysis. Obes Surg 2018; 28: 2836-2843
  • 36 da Ponte-Neto AM, Bernardo WM, de A Coutinho LM. et al. Comparison between enteroscopy-based and laparoscopy-assisted ERCP for accessing the biliary tree in patients with Roux-en-Y gastric bypass: systematic review and meta-analysis. Obes Surg 2018; 28: 4064-4076
  • 37 Skinner M, Popa D, Neumann H. et al. ERCP with the overtube-assisted enteroscopy technique: A systematic review. Endoscopy 2014; 46: 560-572
  • 38 Inamdar S, Slattery E, Sejpal DV. et al. Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc 2015; 82: 9-19
  • 39 Wang TJ, Ryou M. Evolving techniques for endoscopic retrograde cholangiopancreatography in gastric bypass patients. Curr Opin Gastroenterol 2018; 34: 444-450