Mo1453 Gastrostomy-Assisted Transgastric ERCP Is Superior to Single-Balloon-Enteroscopy-Assisted ERCP in Performing Therapeutic Interventions but Is Likely Associated With More Complications in Patients With Surgically Altered Anatomy

Abstract

Gastrostomy-Assisted Transgastric ERCP Is Superior to SingleBalloon-Enteroscopy-Assisted ERCP in Performing Therapeutic Interventions but Is Likely Associated With More Complications in Patients With Surgically Altered Anatomy Mary Flynn, Bezawit D. Tekola, Bruce D. Schirmer, Peter T. Hallowell, Paul Yeaton, Dawn G. COX, Monica Gaidhane, Vanessa M. Shami, Bryan G. Sauer, Michel Kahaleh, Andrew Y. Wang* Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA; Department of Surgery, University of Virginia, Charlottesville, VA; Carilion Clinic Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA; Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY Background: ERCP in patients with surgically altered gastroduodenal anatomy is often unsuccessful using a duodenoscope or standard enteroscope. Singleballoon-enteroscopy-assisted ERCP (SBE-ERCP) and gastrostomy-assisted transgastric ERCP (TG-ERCP) are effective methods of performing ERCP in patients with altered anatomy, such as Roux-en-Y (RY) gastric bypass (GB), but studies comparing these two modalities are lacking. Aim: To compare the therapeutic efficacy as well as complication rates between TG-ERCP and SBEERCP in patients with surgically altered anatomy. Methods: ICD-9 codes, CPT codes, and endoscopy records at a tertiary-care academic hospital were used to identify patients with surgically altered anatomy who underwent attempted TGERCP or SBE-ERCP from 1/1/01-9/10/12. Prior to TG-ERCP, patients received an open Stamm gastrostomy, after which the tract was left to mature several weeks before ERCP. The gastrostomy was dilated to at least 12 mm prior to advancement of a duodenoscope (TJF-160VF, Olympus), and TG-ERCP was performed using short-wire devices. SBE-ERCP was performed using an enteroscope (SIF-Q180, Olympus), with or without a cap, and an overtube (STSB1, Olympus). Specialized long wires and devices were used. Intention-to-treat analyses for therapeutic ERCP success and complications were conducted by analyzing cases (not patients).Treatment groups were compared using the Fisher’s exact test. Results: 47 patients (59 cases) (median age: 53 years, range: 28-83 years) with surgically altered anatomy were included (Table 1). 29 patients (22 women, median age: 56 years, range: 28-83 years) underwent attempted SBE-ERCP, comprising a total of 35 attempted cases. 18 patients (16 women, median age: 52 years, range: 37-63 years) underwent attempted TG-ERCP, comprising a total of 24 cases. SBE-ERCP reached the ampulla/pancreatic/biliary orifice in the afferent jejunal limb in 77% (27/35) of cases vs. 100% (24/24) in the TG-ERCP group (P 0.017). 80% (28/35) of cases in the SBE group required therapeutic ERCP after diagnostic ERCP vs. 100% (24/24) in the TG group (P 0.035). The therapeutic success rate was 64% (18/28) for SBE-ERCP vs. 96% (23/24) for TG-ERCP (P 0.007) (Figure 1). Complications from SBE-ERCP occurred in 9% (3/35) vs. 38% (9/24) of cases in the TG-ERCP group (P 0.075). Pancreatitis occurred following 9% of SBE-ERCP and 8% of TG-ERCP cases (P NS). Conclusions: TG-ERCP was significantly more effective at enabling therapeutic ERCP as compared to SBE-ERCP in patients with surgically altered anatomy. However, TG-ERCP is limited to patients with RYGB and typically delays therapeutic ERCP. TG-ERCP was also associated with a higher rate of complications, which trended towards statistical significance. In patients with RYGB who require ERCP, and cannot wait for gastrostomy maturation, SBE-ERCP is a reasonable first therapeutic option.