EUS-directed transgastric endoscopic retrograde cholangiopancreatography versus laparoscopic-assisted ERCP versus deep enteroscopy-assisted ERCP for patients with RYGB

Abstract

Background and study aims Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is a novel technique for managing pancreaticobiliary diseases in patients with a history of Roux-en-Y Gastric Bypass (RYGB). It has shown to have high technical success rates and fewer adverse events as compared to laparoscopic-assisted ERCP (LA-ERCP). We compared the technical success and clinical outcomes of EDGE vs. LA-ERCP vs. E-ERCP.

Patients and methods A retrospective chart review was performed for 56 patients, of whom 18 underwent LA-ERCP, 12 underwent E-ERCP, and 26 had EDGE, and a comparison of technical success and complication rates was done.

Results Baseline demographic characteristics of patients undergoing these procedures, including age and gender, were comparable. The technical success rate for patients in the EDGE group were 100 % (n = 26), compared with 94 % (n = 17) and 75 % (n = 9) in the LA-ERCP and E-ERCP groups (P = 0.02). In the EDGE group, 8 % of patients (n = 2) had bleeding, and 4 % of patients (n = 1) had lumen-apposing metal stent migration occur during the procedure. In the LA-ERCP group 6 % (n = 1) of patient had bleeding, 6 % (n = 1) post-ERCP pancreatitis and 6 % (n = 1) were diagnosed with an intra-abdominal infection post-procedure. Time to complete the EDGE procedure was significantly shorter at 79 ± 31 mins, compared with 158 ± 50 mins for LA-ERCP and 102 ± 43 mins for E-ERCP (P < 0.001).

Conclusion EDGE is a novel procedure with short procedure times and an effective alternative to LA-ERCP and E-ERCP in management of pancreaticobiliary diseases in patients with a history of RYGB.

Publication History

Received: 06 January 2020

Accepted: 30 March 2020

Article published online:
16 June 2020

• References

• 1 Adult obesity facts: Overweight & obesity. Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/adult.html
• 2 Estimate of bariatric surgery numbers, 2011–2017. American Society for Metabolic and Bariatric Surgery. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers
• 3 Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg 2011; 98: 1345-1355
• 4 Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. SAGES abstract archives. https://www.sages.org/meetings/annual-meeting/abstracts-archive/complications-of-laparoscopic-transgastric-ercp-in-patients-with-roux-en-y-gastric-bypass/
• 5 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
• 6 Kedia P, Kumta NA, Sharaiha R. et al. Bypassing the bypass: EUS-directed transgastric ERCP for Roux-en-Y anatomy. Gastrointest Endosc 2015; 81: 223-224
• 7 James HJ, James TW, Wheeler SB. et al. Cost-effectiveness of endoscopic ultrasound-directed transgastric ERCP compared with device-assisted and laparoscopic-assisted ERCP in patients with Roux-en-Y anatomy. Endoscopy 2019; 11: 1051-1058
• 8 Law R, Leal C, Dayyeh BA. et al. Role of immunosuppression in post–endoscopic retrograde cholangiopancreatography pancreatitis after liver transplantation: A retrospective analysis. Liver Transpl 2013; 19: 1354-1360
• 9 Kedia P, Sharaiha RZ, Kumta NA. et al. Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology 2014; 147: 566-568
• 10 Wang BCM, Furnback W. Modelling the long-term outcomes of bariatric surgery: A review of cost-effectiveness studies. Best Pract Res Clin Gastroenterol 2013; 27: 987-995
• 11 Martin A, Kistler CA, Wrobel P. et al. Endoscopic ultrasound-guided pancreaticobiliary intervention in patients with surgically altered anatomy and inaccessible papillae: A review of current literature. Endosc Ultrasound 2016; 5: 149-156
• 12 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
• 13 Dhindsa BS, Dhaliwal A, Mohan BP. et al. EDGE in Roux-en-Y gastric bypass: How does it compare to laparoscopy-assisted and balloon enteroscopy ERCP: a systematic review and meta-analysis. Endosc Int Open 2020; 8: E163-E171
• 14 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: a multicenter early comparative experience of clinical outcomes. J Clin Gastroenterol 2019; 53: 304-308
• 15 Kedia P, Kumta NA, Widmer J. et al. Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique. Endoscopy 2015; 47: 159-163
• 16 James TW, Baron TH. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a single-center US experience with follow-up data on fistula closure. Obes Surg 2019; 29: 451-456