Endoscopic Ultrasound-Directed Transgastric ERCP Research Articles

Endoscopic ultrasound-directed transgastric ERCP for disconnected pancreatic duct syndrome: finding the edge to bridge the gap.

Endoscopic ultrasound-directed transgastric ERCP for disconnected pancreatic duct syndrome: finding the edge to bridge the gap.

An unusual complication following endoscopic ultrasound-directed transgastric ERCP in a patient with a history of bariatric surgery.

An unusual complication following endoscopic ultrasound-directed transgastric ERCP in a patient with a history of bariatric surgery.

S1272 Comparing Endoscopic Ultrasound-Directed Transgastric ERCP, Enteroscopy-Assisted ERCP, and Laparoscopic-Assisted ERCP in Roux-en-Y Gastric Bypass: A Network Meta-Analysis

S1272 Comparing Endoscopic Ultrasound-Directed Transgastric ERCP, Enteroscopy-Assisted ERCP, and Laparoscopic-Assisted ERCP in Roux-en-Y Gastric Bypass: A Network Meta-Analysis

Endoscopic treatment of bile duct stones after bariatric Roux-en-Y gastric bypass through endoscopic ultrasound-directed transgastric ERCP.

Endoscopic treatment of bile duct stones after bariatric Roux-en-Y gastric bypass through endoscopic ultrasound-directed transgastric ERCP.

EUS-Directed Transgastric ERCP (EDGE) Versus Laparoscopy-Assisted ERCP (LA-ERCP) For Roux-En-Y Gastric Bypass (RYGB) Anatomy: Systemic Review and Metanalysis

Objective: Laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP) has gained popularity and was considered the preferred therapeutic option across multiple institutions in managing choledocholithiasis after bariatric surgery. As of recent, a novel procedure, endoscopic ultrasound directed transgastric ERCP (EDGE), has gained popularity across the USA and Europe. We sought to assess and compare the safety and technical success of both procedures. Methods: We conducted a systematic review following the PRISMA guidelines. A total of 925 articles were screened and assessed for inclusions. Two authors independently screend abstracts and titles followed up full-text screening. Articles comparing outcomes between both surgical techniques were included in this study. A meta-analysis was conducted to compare peri-operative outcomes between both procedures. Results: A total of four articles met the inclusion criteria. All four articles were retrospective reviews. The mean age was 52 and the majority were females. When comparing outcomes between both procedures, no difference in adverse events, technical success rates and pancreatitis was detected. Compared to the LA-ERCP cohort, the EDGE cohort had a shorter hospital Length of Stay (LOS) and operative time. Using the Ottawa scale, a moderate risk of bias was assessed across all four articles. Conclusion: Based on the results of this meta-analysis, EDGE was associated with a shorter LOS and operative time with no increased risk of adverse events. Additionally, based procedures had a high technical success rate.

The Emerging Role of Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE)

The Emerging Role of Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE)

Endoscopic ultrasound-directed transgastric ERCP (EDGE): A multicenter US study on long-term follow-up and fistula closure.

Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a safe and efficacious procedure to treat pancreaticobiliary diseases in Roux-en-Y gastric bypass (RYGB). This multicenter study aimed to determine the long-term outcomes of EDGE focusing on fistula persistence rates and post-procedure weight change. Patients and methods Information about patients with Roux-en-Y gastric bypass anatomy who underwent EDGE between 2015 and 2021 from 10 institutions was captured in a registry. Patient demographics, procedural details, and clinical outcomes were analyzed. Results One hundred seventy-two patients were included in the study (mean age 60, 25 % male). Technical success of lumen-apposing metal stent (LAMS) placement was 171 of 172 (99.4 %) while clinical success of intervention was 95%. The mean procedure time was 65 minutes. The most commonly reported complication was stent dislodgement/migration (n = 29, 17). Mean length of time of LAMS duration was 69 days. Mean follow-up time was 6 months. Endoscopic fistula closure was performed in 40 % of patients (69/172) at the time of LAMS removal. Persistence of fistula was observed in 19 of 62 patients (31 %) assessed. Length of LAMS indwell time (days) was a predictor of persistent fistula. The average weight gain while the LAMS was in place was 12 lb in 63 patients (36.6 %); 59.4 % of patients gained < 5 lb. Conclusions EDGE is a safe and efficacious procedure for RYGB patients requiring ERCP. Post-procedure evaluation and management of the enteral fistula varies widely among centers currently and would benefit from further standardization. Fistula persistence appears to be uncommon and can be managed endoscopically but may be related to length of indwell times of the LAMS.

S358 Endoscopic Ultrasound-Directed Transgastric ERCP for Pancreatic Duct Stent Placement to Treat Pancreatic Ascites

Introduction: Endoscopic ultrasound (EUS)-Directed transGastric ERCP (EDGE) is an advanced procedure utilized to enable pancreaticobiliary access in patients with Roux-en-Y gastric bypass anatomy. We hereby present a case of refractory pancreatic ascites from a persistent pancreatic duct (PD) leak treated with EDGE and transpapillary PD stenting. Case Description/Methods: A 62-year-old White female with history of morbid obesity with Roux-en-Y gastric bypass and biliary pancreatitis with prior cholecystectomy was referred for refractory pancreatic ascites causing significant abdominal pain, poor oral intake and weight loss necessitating total parenteral nutrition. MRCP showed a PD leak in the body as cause for ascites (Fig. 1). After multidisciplinary team discussion, a staged EDGE for PD stenting was pursued. The gastric remnant was identified endosonographically through the jejunum, a 19G needle was advanced into it and 500 ml of saline was instilled to dilate the remnant. A 0.025 guidewire was coiled in the remnant and a 15mm by 10 mm cautery enhanced lumen apposing metal stent (LAMS) delivery system was used to create a jejunogastrostomy followed by LAMS deployment. LAMS was post dilated to 15 mm and ERCP was pursued after 10 days. During ERCP, PD leak at the body was confirmed on the pancreaticogram. A 5 Fr by 15 cm single pigtailed stent was deployed to bridge this leak. A large biliary sphincterotomy was also performed for a subjectively stenotic major papilla. Follow up CT scan after 1 month showed resolution of pancreatic ascites and repeat ERCP confirmed resolution of the PD leak. The biliary and pancreatic stents were removed. The jejunogastrostomy stent was removed after three months. She continues to remain asymptomatic and is tolerating a regular diet. Discussion: This case demonstrates the successful use of EDGE procedure for management of refractory pancreatic ascites from a pancreatic duct leak. EDGE for pancreatic endotherapy in Roux-en-Y gastric bypass anatomy is a safe and effective alternative to more invasive laparoscopy or percutaneous gastrostomy access to the gastric remnant and should be considered in cases with ascites. Watch the video at https://tinyurl.com/ACGAbstractS358Figure 1.: MRCP With Pancreatic Duct Leak.

S348 Creating Your Own Paths: EUS-Guided Transjejunal Gallbladder Drainage and ERCP, Cholecystoscopy, and Electrohydraulic Lithotripsy for Choledocholithiasis and Cholelithiasis in a Patient With Roux-en-Y Gastric Bypass

Introduction: Treating choledocholithiasis and cholelithiasis in patients with altered gastrointestinal anatomy is a challenge given the difficulty in accessing the biliary tract using conventional endoscopic techniques. Endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) represents a novel solution to this challenge. It allows access to the excluded stomach allowing safe performance of ERCP and interventional EUS procedures including gallbladder drainage. Case Description/Methods: A 61-year-old man with a history of morbid obesity, Roux-en-Y gastric bypass, and bowel perforation complicated by extensive resection and short gut syndrome, as well as rheumatoid arthritis and chronic kidney disease, presented to clinic for intermittent right upper quadrant pain, nausea, and vomiting. Imaging revealed large cholelithiasis, choledocholithiasis, and biliary dilatation with gallbladder distention. Given his high surgical risk and symptomatic biliary disease, EDGE and EUS-guided management of the large gallstone was planned. The first step was to create a jejunogastrostomy (JG) which was performed using EUS-guided 15mmx10mm lumen-apposing metal stent (LAMS) deployment through the Roux limb into the excluded stomach. ERCP was performed 4 weeks later finding choledocholithiasis, and complete removal of two stones was accomplished. This was followed by EUS-guided gallbladder drainage via JG and successful creation of a cholecystoduodenostomy (CDS) using the 15mmx10mm AXIOS stent system. Direct cholecystoscopy, electrohydraulic lithotripsy and removal of a large gallstone were then performed. Both LAMS from JG and CDS were removed at the end of the procedure. Follow-up upper GI series at 6 weeks showed complete closure of the jejunogastrostomy fistula. Discussion: The EDGE approach provides access to the excluded remnant stomach enabling ERCP and interventional EUS procedures such as gall bladder drainage. In this case, we demonstrate the utility of this procedure in enabling access to the gallbladder and permitting direct cholecystoscopy, electrohydraulic lithotripsy, and removal of a large symptomatic gallstone, thus avoiding long-term percutaneous drains and recurrent symptoms, in addition to the risk of cholecystitis or Mirizzi syndrome from a large gallstone. Watch the video at https://tinyurl.com/ACGAbstractS348

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE) Utilization of Trends Among Interventional Endoscopists.

Endoscopic ultrasound-directed transgastric ERCP (EDGE) has become standard-of-care therapy at many centers for pancreaticobiliary disease in patients with Roux-en-Y Gastric Bypass. In this study, we aimed to evaluate the opinions and practices of endoscopists who perform EDGE. A 22-question utilization of EDGE survey was sent to 36 advanced endoscopists at tertiary care centers in the United States. The two-section survey included questions regarding advanced endoscopy volume and training at the respective facilities, and questions on specific details of EDGE utilization. Among 36 interventional endoscopists (IE) surveyed, 14 (39%) reported performing > 1000 ERCPs annually. Thirty (83%) offered EDGE as an option for Roux-en-Y gastric bypass patients with previous cholecystectomy. Other options offered included: 19 (53%) offered Laparoscopy-assisted ERCP (LA-ERCP), 7 (19%) offered Single-Balloon ERCP (SBE), and 10 (28%) offered percutaneous drainage (PTC). Twenty (56%) IE performed 10 or less EDGE procedures, while 16 (44%) performed 11 or more. Single-session EDGE was performed by 7 (19%) IE, while 15 (42%) performed dual session, and 13 (36%) performed both. 19 (53%) actively closed fistulas while 17 (47%) let them close spontaneously. Thirty one (86%) reported a technical success rate of 91% to 100%. The most frequently reported immediate adverse event post-procedurally was abdominal pain, reported by 17IE (47%). Weight gain was reported by 2IE (6%). EDGE continues to gain in popularity as an option for Roux-en-Y gastric bypass patients requiring pancreaticobiliary interventions, with 24/36IE (67%) believing that it should be the new standard. In addition, most report a low frequency of post-procedural weight gain. ClinicalTrials.gov Identifier NCT05041608.

Endoscopic ultrasound-directed transgastric ERCP: esophageal stent to the rescue.

Endoscopic ultrasound-directed transgastric ERCP: esophageal stent to the rescue.

Endoscopic ultrasound-directed transgastric ERCP (EDGE): a systematic review describing the outcomes, adverse events, and knowledge gaps.

BACKGROUND : Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has emerged as a viable completely endoscopic method for performing pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. The aims of this systematic review were: (1) to describe the indications, outcomes, and complications of EDGE; and (2) to identify deficiencies in our knowledge of important technical approaches and clinical outcomes. METHODS : A systematic review was conducted via comprehensive searches of Medline, Scopus, CINAHL, and Cochrane to identify studies focusing on EDGE outcomes. Simple descriptive statistics were derived from case series only. Case reports were only included to qualitatively describe additional indications, techniques, and adverse events. RESULTS : The initial search identified 2143 abstracts. Nine case series and eight case reports were included. In the nine case series, 169 patients underwent EDGE. The technical success rate was 99 % (168 /169) for gastrogastrostomy/jejunogastrostomy creation and 98 % (166 /169) for subsequent ERCP. Minor adverse events specifically related to EDGE occurred in 18 % (31/169) and included intraprocedural stent migration/malposition (n = 27) and abdominal pain (n = 4). Moderate adverse events specific to EDGE occurred in 5 % (9/169): including bleeding (2 %), persistent fistula (1 %), and perforation (1 %). Severe adverse events occurred in one patient with a perforation requiring surgery. Deficiency in reporting on the clinical significance of adverse events was identified. CONCLUSION : Based on limited observational data, in expert hands, EDGE has a high rate of technical success and an acceptable rate of adverse events. As a novel procedure, many knowledge gaps need to be addressed to inform the design of meaningful comparative studies and guide informed consent.

Endoscopic ultrasound-directed transgastric ERCP facilitating extensive ampullectomy in Roux-en-Y gastric bypass patient.

Endoscopic ultrasound-directed transgastric ERCP facilitating extensive ampullectomy in Roux-en-Y gastric bypass patient.

S1856 Single Session Endoscopic Ultrasound-Directed Transgastric ERCP (“EDGE”) in Roux-en-Y Gastric Bypass Patient With Pancreatic Mass and Biliary Obstruction With Intentional Maintenance of Gastrogastrostomy

S1856 Single Session Endoscopic Ultrasound-Directed Transgastric ERCP (“EDGE”) in Roux-en-Y Gastric Bypass Patient With Pancreatic Mass and Biliary Obstruction With Intentional Maintenance of Gastrogastrostomy

EDGE in Roux-en-Y gastric bypass: How does it compare to laparoscopy-assisted and balloon enteroscopy ERCP: a systematic review and meta-analysis.

Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a new endoscopic procedure to perform ERCP in Roux-en-y gastric bypass (RYGB) patients. The aim of this study was to conduct a systematic review and meta-analysis to evaluate technical success, clinical success and adverse effects of EDGE and compare it to laparoscopic ERCP (LA-ERCP) and balloon ERCP (BE-ERCP). Patients and methods We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, LILACS, SCOPUS, and Web of Science databases to identify studies reporting on EDGE, LA-ERCP, and BE-ERCP. The primary outcome was to evaluate technical and clinical success of all three procedures and the secondary analysis focused on calculating the pooled rate of all adverse events (AEs), along with the commonly reported AE subtypes. Results Twenty-four studies on 1268 patients were included in our analysis with the majority of the population being males with mean age 53.72 years. Pooled rates of technical and clinical success with EDGE wer 95.5 % and 95.9 %, with LA-ERCP were 95.3 % and 92.9 % and were BE-ERCP were 71.4 % and 58.7 %, respectively. Pooled rates of all AEs with EDGE were 21.9 %, with LA-ERCP 17.4 % and with BE-ERCP 8.4 %. Stent migration was the most common AE with EDGE with 13.3 % followed by bleeding with 6.6 %. Conclusion Our meta-analysis demonstrated that the technical and clinical success of EDGE procedure is better than BE-ERCP and comparable to that of LA-ERCP in RYGB patients. EDGE also has a similar safety profile as compared to LA-ERCP but has higher AE rate as compared to BE-ERCP.

Endoscopic ultrasound-directed transgastric ERCP in patients with Roux-en-Y gastric bypass using lumen-apposing metal stents or duodenal self-expandable metal stents. A European single-center experience.

endoscopic ultrasound-directed transgastric ERCP is emerging in Roux-en-Y gastric bypass. a review of 14 consecutive patients. fourteen EUS-directed gastro-gastrostomy/gastro-jejunostomy were performed using lumen-apposing metal stents or duodenal self-expandable metal stents. Single-session ERCP was successful in 9/12 cases and deferred procedures or follow-up in 6/7 cases. Papillary access was obtained in all cases. Dislodgment occurred in 4/19 patients and was handled successfully endoscopically. Transgastric stents were removed after a median of 30 days. No recurrence/fistula were noted after a median of 256 days post-removal. duodenal self-expandable and lumen-apposing metal stents can be used for single-deferred endoscopic ultrasound-directed transgastric ERCP in Roux-en-Y gastric bypass.

919 Outcomes of Endoscopic Ultrasound Directed Trans-Gastric ERCP (EDGE): A Single Center Experience

INTRODUCTION: ERCP can be difficult in patients with Roux-En-Y foregut anatomy due to difficulty accessing the papilla, where balloon-assisted enteroscopy or laparoscopy based access has been used. Endoscopic ultrasound directed trans-gastric ERCP (EDGE) allows access to the excluded stomach via a lumen apposing metal stent (LAMS) from the gastric pouch, and passage of the duodenoscope in standard anatomical fashion. Early studies demonstrated high technical and clinical success rates of EDGE with few major adverse events (AEs). We aimed at describing rates of technical and clinical success and AEs of EDGE, impact on patients’ weight and incidence of persistent gastro-gastric fistulae (GGF). METHODS: This is a single center retrospective analysis of a prospectively collected database. All patients who underwent EDGE from 06/2018 to 05/2019 were included. AEs were defined per ASGE lexicon. Descriptive statistical analysis was used to assess outcomes. RESULTS: Nineteen patients were included in the study [mean age 59.4 years (SD = 10.7); 79% females, Table 1]. Two additional patients with spontaneous GGF noted at planned EDGE had no LAMS placed and were excluded. Choledocholithiasis was the most common indication (7/19, 37%), with three associated with cholangitis. Technical success for EUS guided LAMS placement/GGF creation was 100% (Hot AXIOS, 15 mm × 10 mm) with a mean procedure time of 26.8 (SD = 10) minutes and no major AEs. Same session ERCP was done in 2/19 (10%) with LAMS anchoring and 17/29 ERCPs (90%) performed a mean 5.5 (SD = 4.9) days after LAMS placement with a diagnostic duodenoscope (18/19, 95%) most commonly used. Mean ERCP time was 38.7 (SD = 4.9) min with a technical and clinical success of 95% (18/19). Two ERCP-related moderate adverse events occurred managed endoscopically and conservatively. LAMS were removed within 4 weeks of last ERCP, with APC +/- endoscopic suturing in 13/16 (81%) with 100% technical success of endoscopic closure. There was no weight gain noted on a mean follow up of 11.3(SD = 9) weeks. GGF resolution was confirmed in 5/16 with CT (1/5), Upper GI Series (2/5) or upper endoscopy (2/5) done in 6 months of GGF closure with other patients yet to reach the 6-month time-frame (Table 2). CONCLUSION: EDGE is an effective procedure for patients with Roux-en-Y foregut anatomy, with acceptable safety profile and low risk of persistent GGF or weight gain in this series. Further prospective studies are needed to assess the long-term safety, in regards to weight gain and persistence of GGF.

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

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.

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure

Endoscopic ultrasound-directed transgastric ERCP (EDGE) by creating an anastomosis from the gastric pouch or jejunum to the excluded stomach allows performance of ERCP in Roux-en-Y gastric bypass (RYGB) anatomy. Concern for persistent fistula following stent removal and sparse data limit adoption. Retrospective review of consecutive patients undergoing EDGE over a 2-year period. Nineteen RYGB patients underwent EDGE; three had previously failed ERCP by the device-assisted method. Indications for ERCP were choledocholithiasis (8), recurrent acute pancreatitis (6), benign post-surgical stricture (3), elevated bilirubin, and papillary stenosis (1 each). EDGE was technically successful in all 19 patients with jejunogastric anastomosis in 11 patients and gastrogastric in 8 using a 15-mm lumen-apposing metal stent. Stent malposition occurred in six and was managed by rescue maneuvers. ERCP was performed in the same session in four patients; the remainder were delayed after a mean of 48days. Diagnostic endoscopic ultrasound (EUS) was performed in four patients. No severe adverse events occurred; clinical success was 100%. Stents were removed after a mean dwell time of 182days. Argon plasma coagulation (APC) was used to promote fistula closure in 12 patients. Upper GI series to assess fistula closure was obtained in 11 patients after a mean of 182days following stent removal. One persistent fistula was identified and closed endoscopically. EDGE is an effective modality for performing ERCP in patients with RYGB anatomy and can be performed via gastrogastric or jejunogastric approaches. Persistent fistula is uncommon and can be managed endoscopically. APC may promote fistula closure.

Treatment of Biliary Stent Complications in a Patient With Roux-En-Y Gastric Bypass Using Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): A Case Report

Treatment of Biliary Stent Complications in a Patient With Roux-En-Y Gastric Bypass Using Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): A Case Report