Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using astandardized protocol (with video).

Abstract

Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP. Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed. Forty-five ERCPs were performed in 31 patients (57.4± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n= 28, 90.3%) for biliary stones (n= 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n= 24, 77.4%) and mainly in the middle-excluded stomach (n= 21, 67.7%) with an oblique axis (n= 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n= 8), anastomotic dilation (n= 8), or failure to pass (n= 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P= 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P= 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P= 0.465). The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.