917 EUS-Directed Transgastric ERCP (EDGE) versus Laparoscopy-Assisted ERCP (LAERCP) for Roux-en-Y Gastric Bypass (RYGB): A Single Center Experience

Abstract

INTRODUCTION: The rising obesity epidemic in the US has led to an increase in bariatric surgeries, and Roux-en-Y gastric bypass (RYGB) is a common option. These patients are at higher risk for gallstone disease, but the resulting altered anatomy presents unique challenges to accessing the bile duct. Lap-assisted ERCP (LAERCP) is the most common modality for biliary access in this setting but leads to high resource utilization and morbidity. EUS-directed trans-gastric ERCP (EDGE), is emerging as a new alternative. We present a comparison between the performances of LAERCP and EDGE in RYGB patients at our institution. METHODS: The protocol was approved by the institutional review board. Charts were reviewed for all RYGB cases that underwent LAERCP or EDGE at our health system between 5/2009 – 5/2019. Patient demographics, procedural and clinical information was gathered. Both groups were compared using students T test for continuous variables and Pearson’s chi square and Fisher exact test for categorical variables. RESULTS: A total of 76 RYGB patients (17 EDGE and 59 LAERCP) were analyzed. The mean age, gender and indication for the procedure (biliary vs pancreatic) were similar in both groups. All EDGE and LAERCP were performed in a single step setting. Technical success of obtaining access to the excluded stomach was 100% for both groups. There was no statistical difference in the technical success of therapeutic ERCP between the two groups (94% EDGE vs 100% LAERCP). There was no difference in the adverse event rates between EDGE (6%) and LAERCP (17%). The EDGE group had significantly shorter procedural time as compared to LAERCP (103 vs 208 min, P < 0.001); but there was no difference in the length of hospital stay (2.7 vs 2.6 days, P = 0.94). The median time for lumen-apposing metal stent removal was 22 days (range 0-111). There was no significant weight gain (-6.33 lbs) at median follow up of 35 days in the EDGE group. CONCLUSION: Overall success rate of intended therapeutic intervention and adverse event profile are similar for EDGE and LAERCP. EDGE has significantly shorter procedure time and can be done independently in the endoscopy unit, unlike LAERCP which requires operating room availability and coordination with a skilled laparoscopic surgeon. EDGE can be considered as a safe and effective first line modality for pancreaticobiliary access in RYGB patients offering the benefit of repeat ampullary access if needed on follow up procedure and without any worries of significant weight gain.