EUS-directed Transgastric ERCP Research Articles

Spiral enteroscopy–assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video)

Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (asingle-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.

Closure of an iatrogenic gastrogastric fistula created during EUS-directed transgastric ERCP.

Closure of an iatrogenic gastrogastric fistula created during EUS-directed transgastric ERCP.

EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach

ERCP is challenging in patients with Roux-en-Y gastric bypass. Using EUS to gain access to the excluded stomach and subsequently performing transcutaneous ERCP was described recently. We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). Single-center case series. Tertiary center with expertise in EUS-guided procedures. Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. A linear echoendoscope was used to access the excluded stomach. A LAMS was deployed over a wire to create a gastrogastric or jejunogastric fistula. A duodenoscope was then passed through the LAMS and conventional ERCP was performed. Technical and clinical success rates as well as adverse events. EUS-guided creation of a gastrogastric or jejunogastric fistula via placement of a LAMS was successful in all cases (100%). The ability to perform ERCP through the fashioned fistula during the index procedure was successful in 3 of 5 cases (60%). Two LAMS dislodgments requiring restenting were observed. No major adverse events were observed. No weight regain occurred. The median procedure time was 68.0 minutes. Small sample, single-institution experience. The internal EDGE procedure may offer a cost-effective, minimally invasive option for a common problem in a growing patient demographic. Further refinement of the technique is required to minimize adverse events. ( NCT01522573.).

Bypassing the bypass: EUS-directed transgastric ERCP for Roux-en-Y anatomy

Patients with Roux-en-Y gastric bypass (RYGB) pose distinct challenges to performing ERCP. We propose an alternative endoscopic approach that uses EUS to gain PEG access to the excluded stomach in patients with RYGB anatomy. This video (Fig. 1; Video 1, available online at www.giejournal.org) describes an EUS-directed transgastric ERCP (EDGE) in 6 patients with RYGB anatomy (5 women, 1 man, average age 50.7 years) with biliary disease done by 2 expert biliary endoscopists. The EDGE technique is divided into 2 stages performed during separate endoscopic sessions, with mean procedure times of 81 and 98 minutes. The first stage of the procedure involved placement of a 16F PEG tube into the excluded stomach by using EUS guidance. During the second stage, ERCP was performed in an antegrade fashion through the fashioned gastrostomy after replacement of the PEG tube with a transcutaneous, fully covered, metal esophageal stent. EUS-guided access to the excluded remnant stomach was successful in all 6 patients (100%). Antegrade ERCP was successfully achieved in all 6 patients (100%), with a mean 5.8 days between the 2 stages. Given the high success rates of our recent experience, we propose that EDGE may provide a cost-effective, minimally invasive option for a common problem in a growing patient demographic.