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Abstract

We appreciate the interest of Mutignani et al1Mutignani M. Bonato G. Dioscoridi L. et al.EUS-guided enteroenteral bypass for transenteric ERCP: building on prior knowledge.Gastrointest Endosc. 2021; 93: 279Abstract Full Text Full Text PDF Scopus (1) Google Scholar in our article on EUS-directed transenteric ERCP (EDEE) for the management of pancreatobiliary disease in patients with non–Roux-en-Y gastric bypass surgical anatomy.2Ichkhanian Y. Yang J. James T.W. et al.EUS-directed transenteric ERCP in non–Roux-en-Y gastric bypass surgical anatomy patients (with video).Gastrointest Endosc. 2020; 91: 1188-1194Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In our case series, we highlighted the experience of 7 international tertiary care centers on performing de novo enteroenteral anastomosis using a lumen-apposing metal stent (LAMS) for the management of pancreatobiliary (PB) diseases in patients with non-RYGB surgically altered anatomy. Mutignani et al1Mutignani M. Bonato G. Dioscoridi L. et al.EUS-guided enteroenteral bypass for transenteric ERCP: building on prior knowledge.Gastrointest Endosc. 2021; 93: 279Abstract Full Text Full Text PDF Scopus (1) Google Scholar appropriately highlighted the promising outcomes of EDEE for the management of pancreatobiliary diseases, particularly in cases where multiple interventions are anticipated. EDEE is a technically challenging procedure, and an essential step is the identification of the afferent or the target limb in the setting of complex altered anatomy. In the case series reported by Mutignani et al3Mutignani M. Forti E. Larghi A. et al.Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy.Endoscopy. 2019; 51: 1146-1150Crossref PubMed Scopus (10) Google Scholar in April 2019, a percutaneous transhepatic biliary drainage (PTBD) catheter was used to opacify and distend the afferent limb in the majority of cases. This was followed by transluminal advancement and deployment of a biflanged fully covered self-expandable metal stent. For patients who have initially undergone percutaneous biliary decompression, the PTBD catheter can be used to inject saline/contrast solution to distend the afferent limb and facilitate subsequent EDEE. We propose that PTBD for the sole purpose of facilitating EDEE can often be avoided. We have previously described the “direct EUS puncture” technique for identifying and opacifying the afferent limb as opposed to using other techniques such as PTBD.4Brewer Gutierrez O.I. Runge T. Ichkhanian Y. et al.Lumen-apposing metal stent for the creation of an endoscopic duodenojejunostomy to facilitate bile duct clearance following Roux-en-Y hepaticojejunostomy.Endoscopy. 2019; 51: E400-E401Crossref PubMed Scopus (3) Google Scholar In the direct technique, the afferent limb is identified by EUS by following the hepatic duct insertion into the small bowel. This small bowel loop is punctured with a 19-gauge needle, and saline/contrast solution is injected. Filling of the afferent limb (and possibly opacification of the biliary tree) confirms accessing the correct limb. This is then followed directly with the advancement of a cautery-tipped lumen-apposing metal stent. In our study, the majority (15/18) of patients underwent EDEE by the direct technique, and none required PTBD before EDEE. We believe this decreases the overall invasiveness of this approach and diminishes the number of procedures required. Dr Khashab is a consultant for Boston Scientific, Medtronic, and Olympus. The other authors disclosed no financial relationships. EUS-guided enteroenteral bypass for transenteric ERCP: building on prior knowledgeGastrointestinal EndoscopyVol. 93Issue 1PreviewWe read with interest the article from Ichkhanian et al.1 On the basis of our experience, we fully agree that EUS-guided enteroenteral anastomosis is a safe and effective technique to gain access to the biliary tree and perform ERCP in patients with surgically altered anatomy. Indeed, the present article is not the first report of such a procedure. In 2014, Perez-Miranda et al2 reported the first EUS-guided transenteric anastomosis performed to treat a recurrent biliary malignancy in altered anatomy. Full-Text PDF