ERCP in patients with Roux-en-Y gastric bypass: is there a one-procedure-fits-all approach?

The obesity epidemic is increasing worldwide and has resulted in an increase in bariatric surgery. The Roux-en-Y gastric bypass (RYGB) remains one of the most commonly performed bariatric procedures [1]. One of the consequences of the surgery is an increased risk of choledocholithiasis. This surgery excludes most of the stomach and the duodenum making conventional endoscopic retrograde cholangiopancreatography (ERCP) impossible. As a result, there are three main alternative approaches to conventional ERCP: (i) laparoscopic-assisted ERCP (LA-ERCP); (ii) balloon enteroscopy-assisted ERCP (BEA-ERCP); and (iii) endoscopic ultrasound-directed transgastric ERCP (EDGE).

LA-ERCP has historically been the standard technique. A surgeon provides laparoscopic access to the excluded stomach. This is followed by conventional ERCP using a traditional duodenoscope that allows for high success rates [2]. It also affords an opportunity to perform a same-session cholecystectomy, if required. Challenges include: schedule coordination between surgeons and endoscopists; the need to leave a gastrostomy tube in situ if multiple ERCPs are required; its invasive nature; and its increased adverse event rate compared with standard ERCP [2].

BEA-ERCP uses a single- or double-balloon enteroscope to travel down the Roux limb to the entero – entero anastomosis, biliary limb, and papilla. The main advantage is that it does not require a surgical procedure or creation of a gastrostomy/fistula. In addition, the adverse event profile is favorable compared with the other options [3]. However, it can be a technically difficult procedure owing to adhesions from prior surgery, sharp anastomotic angles to traverse, and the tangential views of the papilla given by the forward-viewing scope causing difficulty during cannulation. Moreover, the smaller diameter channel and lack of elevator do not allow for standard ERCP equipment to be used or deployed in the usual fashion. Procedure success rates have been reported to be as high as 91 % in very high volume expert centers [4], but most studies have shown procedural success rates closer to 70 % in tertiary centers [3] [5].

“if the patient requires a cholecystectomy, LA-ERCP is likely the preferred approach. If cholecystectomy is not needed, the options are BEA-ERCP vs. EDGE to avoid surgery and the higher adverse event rates associated with LA-ERCP.”

The EDGE procedure allows the endoscopist to create a fistula between the gastric pouch and the excluded stomach via a lumen-apposing metal stent [6]. The ERCP is performed in a subsequent session to avoid dislodging the stent and creating a perforation between the two stomachs. Alternatively, the stent can be sutured in and a same-session ERCP performed. The main advantage to EDGE is that it is performed by only the endoscopist, in the endoscopy suite, using the standard duodenoscope for the ERCP component. The disadvantage is that it is a highly technical procedure requiring expertise in interventional endoscopic ultrasound (EUS), ERCP, and possibly endoscopic suturing. There are also concerns over persistent fistula formation that can reverse the bypass, as well as higher procedural adverse event rates compared with standard ERCP (21.9 % in one meta-analysis) [7].

In this issue of Endoscopy, Tonnesen et al. report on a retrospective series from their hospital on the outcomes of LA-ERCP vs. BEA-ERCP in patients with RYGB from May 2013 to December 2017 [8]. Their university hospital has two gastrointestinal endoscopy centers that specialize in either LA-ERCP or BEA-ERCP. BEA-ERCP was performed with a single-balloon enteroscope. The outcomes examined were procedural success, adverse events, and outcomes when adjusting for the learning curve. A total of 79 procedures (40 BEA-ERCPs and 39 LA-ERCPs) were performed in 68 patients by six experienced endoscopists and nine experienced surgeons. The procedure success rates were 72.5 % for BEA-ERCP vs. 87.2 % for LA-ERCP (P = 0.14). The adverse event rates were similar (18 % vs. 28 %, respectively; P = 0.23).

A learning curve was appreciated for both procedures. For BEA-ERCP, the success rate went from 50 % to 75 % (P = 0.002); for LA-ERCP, it went from 88 % to 100 % (P < 0.001 %) when comparing success rates from the first quintile to the last.

The authors conclude that in experienced hands both BEA-ERCP and LA-ERCP are effective and feasible procedures in patients with RYGB anatomy. They suggest that those in need of cholecystectomy undergo LA-ERCP, while the remaining patients undergo BEA-ERCP.

Overall, I laud the authors for reporting the largest series to date on the comparison of these two procedures. Previous studies, as mentioned by the authors, have shown LA-ERCP to be superior to BEA-ERCP with regards to procedure success. The authors show that, in a highly skilled tertiary center, procedural success with BEA-ERCP can be equivalent to LA-ERCP, thus avoiding surgery. It should be noted that the retrospective design and the variability between the procedure indications of the two groups do limit the results. However, short of a multicenter randomized three-arm trial comparing LA-ERCP, BEA-ERCP, and EDGE (which would be extremely hard to carry out), this type of study is the best evidence we can expect to have.

Based on this study, should BEA-ERCP be the first-line approach for ERCP in patients with RYGB anatomy? Unfortunately, the answer is not that easy, and a one-procedure-fits-all approach is not possible. We must take into account the expertise of the medical center and the needs of the patient. I agree with the authors that, if the patient requires a cholecystectomy, LA-ERCP is likely the preferred approach. If cholecystectomy is not needed, the options are BEA-ERCP vs. EDGE to avoid surgery and the higher adverse event rates associated with LA-ERCP. Both BEA-ERCP and EDGE require specialized technical skills in order to achieve procedure success. If a center does not specialize in these procedures, either LA-ERCP or transfer to a specialized center should be considered. If repeated procedures are required (e. g. for biliary stricture) or complex therapy requiring routine ERCP equipment is needed (e. g. a large stone), EDGE may be the preferred choice. Otherwise, BEA-ERCP can be a first-line approach in specialized centers that have high procedural success rates. This approach can avoid surgery, the creation of fistulas, and has a more favorable adverse event profile compared with other approaches [3].

In conclusion, ERCP in patients with RYGB anatomy is challenging. Whenever there are multiple options for a clinical problem, it usually means that a one-procedure-fits-all approach is not possible. However, as shown by the authors and described in this editorial, BEA-ERCP is definitely a great first-line approach for centers that have the endoscopic expertise.

Publication History

Article published online:
28 July 2020

• References

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