S0054 Gaining an EDGE: A Single Center Experience with EUS-Directed Transgastric ERCP and EUS

Abstract

INTRODUCTION: Roux-en-Y anatomy presents a unique challenge for patients needing ERCP or upper EUS. EUS-directed transgastric ERCP (EDGE) is an alternative to laparoscopy- or enteroscopy-assisted ERCP for these patients. Successful diagnostic upper EUS via this approach has been reported as well. We reviewed EDGE procedures performed at our center to measure technical and clinical success, and identify factors potentially associated with stent migration. METHODS: Demographics and procedure data were collected by chart review for patients undergoing EDGE procedures from February 2018 to November 2019. Technical success was defined as access to the excluded stomach following lumen apposing metal stent (LAMS) placement. Clinical success was defined as successful performance of ERCP or EUS either at the index procedure (single stage) or after fistula maturation (two stage). Change in weight was recorded for the duration the LAMS was in place. Fisher’s Exact Test was used to compare rates of stent migration between patients undergoing EDGE with 15 mm and 20 mm LAMSs, via gastro-gastric and entero-gastric routes, and as a single or two stage procedure. RESULTS: 32 EDGE procedures were performed in 29 patients (Table 1). Technical success was seen in 31 of 32 procedures (96.9%). Clinical success was seen in 27 of 32 procedures (84.4%). 19 stents were removed after an average of 59.7 days and the average weight change from stent placement to removal was -2.4 kg. Stent migration occurred in 8/32 (25%) procedures (Table 2). There was no significant difference in rates of migration between 15 mm and 20 mm stents (35.7% vs 17.6%; P = 0.41), between gastro-gastric, and entero-gastric routes (26.1% vs 22.2%; P = 1) and between single and two session EDGE (25% vs 26.7%; P = 1). Serious adverse events attributable to EDGE occurred in 2/32 procedures (6.2%) both of which were occurrences of stent migration requiring surgery. CONCLUSION: Our study supports the previously seen high clinical success rate for EUS guided transgastric access for ERCP and EUS. With the caveat of a small sample size, we did not see a significant difference in stent migration between single and two session procedures. This may support the decision to perform ERCP in the same session as fistula creation, particularly with time sensitive indications like acute cholangitis. Larger studies are needed to identify patient and procedural factors which may contribute to stent migration and other adverse events in EDGE.Table 1.: Patient and Procedure Characteristics.Table 2.: Stent Migration Characteristics.