921 Efficacy and Safety of Endoscopic Ultrasound-Directed Transgastric ERCP in Gastric Bypass Patients: A Systematic Review and Meta-Analysis

Abstract

INTRODUCTION: Treating pancreaticobiliary disorders in Roux-En-Y gastric bypass patients poses a technical challenge for physicians. The traditional laparoscopic or device assisted enteroscopic techniques has high post procedural complications and failure rates. EUS directed transgastric ERCP (EDGE), which accesses the ampulla by creating a temporary fistula through the remnant stomach for standard ERCP, has shown promising results. We conducted a systematic review and meta-analysis to evaluate and compare the efficacy and safety of EDGE. METHODS: MEDLINE, EMBASE, and SCOPUS databases were utilized to search for eligible studies that reported on efficacy and safety from 2012-2019. Efficacy was defined as the ability to create a temporary fistula through a lumen apposing metal stent (LAMS) and conduct an ERCP. Safety included assessing adverse events. The studies included were retrospective studies and were assessed with the NHBLI tool. Figure 1 depicts the flow chart used for study screening. RESULTS: A total of 4 studies (n = 88 patients) were included in the analysis. The mean age of patients undergoing EDGE was 56 years with 86% females. All patients evaluated were status post roux-en-y gastric bypass and the most common indication for the procedure was choledocholithiasis. Pooled technical success was 98.8% (95% CI 0.96-1.0) although 13 cases involved either LAMS misdeployment or LAMS migration during ERCP requiring rescue or repositioning. A total of 8 adverse events (8% 95% CI 0.03-0.16) occurred including intra-procedural bleeding, pancreatitis, persistent fistula formation or perforation. Figures 2,3 highlight the clinical success and adverse events of the EDGE technique. CONCLUSION: EUS directed transgastric ERCP (EDGE) appears to be an effective and safe procedure for Roux-EN-Y gastric bypass patients to undergo ERCP. Further studies are needed to address optimal procedural techniques, including access tract closure and to assess long term adverse events such as post procedural weight gain.