Transgastric ERCP Research Articles

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

S1137 Analysis of Off-Label Usage of Lumen Apposing Metal Stents in the GI Tract: A Single Center Experience

Introduction: Lumen apposing metal stents (LAMS) have revolutionized our approach to pancreatic fluid collections (PFCs). In addition to tremendous success in safely and effectively managing PFCs, LAMS have been utilized in other interventions including EUS-guided gallbladder drainage (EUS-GBD), EUS-directed transgastric ERCP (EDGE), EUS-guided transgastric intervention (EDGI), EUS-guided gastrojejunostomy (EUS-GJ), EUS-guided choledochoduodenostomy (EUS-CD), EUS-guided drainage of post-operative collection (EUS-PO) and stricture dilation (SD). There is limited research on the use of LAMS for these off-label indications. We present our experience using LAMS in the management of conditions other than pancreatic fluid collections. Methods: All patients who underwent LAMS placement between March 2015-October 2021 were added to a prospectively maintained database. Collected data including patients’ demographics, procedure details, clinical outcomes, and adverse events was retrospectively reviewed. All patients who underwent LAMS placement for PFCs were excluded from the analysis. Descriptive statistics were used to summarize our findings. Results: A total of 191 patients underwent LAMS placement during the study period. Of these, 65 patients had indications outside of drainage of PFCs. This included EUS-GBD (25), EDGE (6), EDGI (2), EUS-GJ (11), EUS-CD (4), SD (6), EUS-PO (9), and miscellaneous (2) (Table). The average age was 65.7 years (SD 8.6) and 24 were female (36.9%). Technical success was achieved in 63 patients (96.9%). The diameter of LAMS used included 8mm (n=2), 10mm (n=23), 15mm (n=17), and 20mm (n=21). The average procedure time was 39.4 minutes (SD 5.3) and the average duration of LAMS placement was 36.2 days (SD 8.5). Clinical success was achieved in 57/63 patients (90.5%); however, this was much lower for patients who underwent LAMS placement for stricture dilatation (50%). LAMS was left indefinitely in 24 patients (38.1%). Adverse events occurred in six patients (9.2%). Conclusion: LAMS provide an effective and safe modality for securing endoscopic access and allowing interventions outside of PFCs. However, the efficacy of LAMS for managing gastrointestinal strictures remains in question. Table 1. - Summary of usage of LAMS in the GI Tract EUS-GBD (n=25) EDGE (n=6) EDGI (n=2) EUS-GJ (n=11) EUS-CD (n=4) SD (n=6) EUS-PO (n=9) Miscellaneous (n=2) Age, mean, SD 73.64, 12.0 65.8, 8.1 61.0, 9.9 64.5, 13.0 65.3, 17.0 55.2, 11.75 52.0, 18.5 71, 66 Female gender, n, % 6, 24% 5, 83.3% 1, 50% 2, 18% 3, 75% 5, 83% 2, 22.2% 0, 0% Indications, n % Calculous Cholecystitis, 15, 60% Choledocholithiasis (n=4, 66.7%) Pancreatic mass (n=1, 50%) Malignant GOO, 11, 100% Distal malignant biliary obstruction, 4 100% Anastomotic stricture, 4 (67%) Post-operative fluid collections, 9, 100% Liver abscess, 2, 100% Malignant cholecystitis, 5, 20% Acalculous cholecystitis, 2, 8% Benign papillary stenosis (n=2, 33.3%) Pancreatic cyst (n=1, 50%) Pyloric stricture, 2 (33%) Malignant biliary obstruction, 3, 12% Technical success, n, % 23, 92.0% 6, 100% 2, 100% 11, 100% 4, 100% 6, 100% 9, 100% 2, 100% Clinical success, n, % 21/23, 91.3% 6, 100% 2, 100% 11, 100% 4, 100% 3, 50% 8, 88.9% 2, 100% Procedure duration (min), mean, SD 39.5, 21.7 38.7, 20.0 52, 17.0 66, 31.6 24.5, 13.3 18.7, 3.8 27.3, 9.1 28, 7.1 Duration of LAMS placement, mean, SD 47.9, 27.0 30.3, 11.6 28, 0 N/A N/A 68.5, 26.7 47.3, 28.2 39, 5 Adverse events, n, % 4, 18% 0, 0% 1, 50% 0, 0% 0, 0% 1, 16.7% 0, 0% 0, 0% Length of follow-up (days), mean, SD 47.3, 27.9 208.2, 179.1 240, 144.2 46.50, (28.3, 82.8) 143, 119.9 292, 171.2 565.8, 465.1 43.5, 53.0

Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography and transpapillary gallbladder drainage

Video 1.

Initial United Kingdom experience of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography.

Gallstone disease is a recognized complication of bariatric surgery. Subsequent management of choledocholithiasis may be challenging due to altered anatomy which may include Roux-en-Y gastric bypass (RYGB). We conducted a retrospective service evaluation study to assess the safety and efficacy of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in patients with RYGB anatomy. All the patients who underwent EDGE for endoscopic retrograde cholangiopancreatography after RYGB at two tertiary care centers in the United Kingdom between January 2020 and October 2021 were included in the study. Clinical and demographic details were recorded for all patients. The primary outcome measures were technical and clinical success. Adverse events were recorded. Hot Axios lumen apposing metal stents measuring 20 mm in diameter and 10 mm in length were used in all the patients for creation of a gastro-gastric or gastro-jejunal fistula. A total of 14 patients underwent EDGE during the study period. The majority of the patients were female (85.7%) and the mean age of patients was 65.8 ± 9.8 years. Technical success was achieved in all but one patient at the first attempt (92.8%) and clinical success was achieved in 100% of the patients. Complications arose in 3 patients with 1 patient experiencing persistent fistula and weight gain. In patients with RYGB anatomy, EDGE facilitated biliary access has a high rate of clinical success with an acceptable safety profile. Adverse events are uncommon and can be managed endoscopically.

The Outcome of Laparoscopy-Assisted Transgastric Rendezvous ERCP During Cholecystectomy After Roux-en-Y Gastric Bypass Compared to Normal Controls.

The Outcome of Laparoscopy-Assisted Transgastric Rendezvous ERCP During Cholecystectomy After Roux-en-Y Gastric Bypass Compared to Normal Controls.

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-guided gastrointestinal anastomosis: Current status and future perspectives.

Both clinical experience and supporting data have improved drastically in the context of endoscopic ultrasound-guided gastrointestinal anastomosis (EUS-GIA). Where outcomes used to be questioned, focus has now moved towards performing comparative studies, optimizing technical approaches, improving patient selection, and developing well-defined treatment algorithms. The purpose of this review is to provide an overview of technical developments within EUS-GIA and to discuss the current status of EUS-GIA and future directions. EUS-GIA techniques such as EUS-guided gastroenterostomy (EUS-GE), EUS-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) and EUS-guided treatment afferent loop syndrome have undergone further development, refining technical approaches, improving patient selection and subsequent outcomes. Retrospective evaluations of EUS-GE have shown similar safety when compared to enteral stenting, whilst attaining surgical range efficacy. Whereas, in patients with gastric bypass anatomy, EDGE seems less cumbersome and time consuming than enteroscopy-assisted ERCP, while preventing surgical morbidity associated with laparoscopy-assisted ERCP. Although less evidence is available on EUS-guided treatment of afferent loop syndrome, this technique has been associated with higher clinical success and fewer reinterventions and adverse events when compared to enteral stenting and percutaneous drainage, respectively. Several randomized studies are currently underway evaluating EUS-GE in malignant gastric outlet obstruction (GOO), whereas more prospective data are still required on EDGE and long-term fistula management. EUS-GIA has become a crucial alternative to established techniques, overcoming technical limitations and subsequently improving patient outcomes. Although we should focus on prospective confirmation of these results in the context of GOO and EDGE, the current evidence already allows for a prominent role for EUS-GIA in our everyday practice.

EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience

Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n= 16) and management of pancreatic fluid collections (n= 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n= 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n= 28) and EUS-guided cystgastrostomy (n= 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P= .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.

EUS-directed transgastric ERCP in Roux-en-Y gastric bypass revision of sleeve gastrectomy.

Video 1EUS-directed transgastric ERCP in Roux-en-Y gastric bypass revision of sleeve gastrectomy.

Comparison of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography outcomes using various technical approaches.

Background and study aims Roux-en-Y gastric bypass presents an anatomic challenge for patients needing ERCP. EUS-directed transgastric ERCP (EDGE) offers high clinical success but carries considerable risk of adverse events (AEs) with no standardized technical approach. In our study, we review the safety and efficacy of our various EDGE technical approaches. Patients and methods A retrospective single-center study of all patients who underwent EDGE procedures between February 2018 and November 2019. Primary outcomes included comparing the technical and clinical success, AEs, and lumen-apposing metal stent (LAMS) migration rates per access route (gastrogastric vs jejuno-gastric), number of procedure stages (single-stage vs two-stage), and stent size (15 mm vs 20 mm). Secondary outcomes included LAMS migration characteristics and management. Results Thirty-two EDGE procedures were performed in 29 patients, including 17 single-stage and 15 two-stage procedures, 23 gastrogastric, and nine jejuno-gastric routes, fourteen 15-mm and 17 20-mm LAMS. Overall technical and clinical success rates were 96.9 % and 87.1 %, respectively, without any significant difference between groups. The overall AE rate was (34.4 %) and was significantly lower in the 20-mm LAMS group compared to the 15-mm group (17.6 % vs 57.1 %, P = 0.03). Compared to two-stage procedures, there was no significant difference in AEs with single-stage procedures (35.3 % vs 33.3 %, P = 0.33). The LAMS migration rate was (25 %) with no significant difference between groups. Most migrations were around the index procedure and managed endoscopically (62.5 %). Conclusions EDGE offers high clinical success rates but AE rates remain significant. In our series, a 20-mm LAMS resulted in a significantly lower AE rate than the 15-mm LAMS. Large multicenter studies are recommended to identify technical factors leading to an optimal EDGE procedure.

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

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

Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis.

Several therapeutic modalities have been proposed for the management of choledocholithiasis (CDL) following Roux-en-Y gastric bypass (RYGB), yet debate exists regarding the optimal management. The purpose of our study was to review the current literature to compare the efficacy of various techniques in the management of CDL post-RYGB. A comprehensive search of multiple databases was conducted. Studies reporting on the management of CDL in patients post-RYGB and including at least 5 patients were eligible for inclusion. The primary outcome was successful stone clearance. Secondary outcomes included procedure duration, length of hospital stay, and adverse events. Of 3259 identified studies, 53 studies involving 857 patients were included in the final analysis. The mean age was 54.4years (SD 7.05), 78.8% were female (SD 13.6%), and the average BMI was 30.8kg/m2 (SD 6.85). Procedures described included laparoscopy-assisted ERCP (LAERCP), balloon-assisted enteroscopy (BAE), ultrasound-directed transgastric ERCP (EDGE), laparoscopic common bile duct exploration (LCBDE), EUS-guided intra-hepatic puncture with antegrade clearance (EGHAC), percutaneous trans-hepatic biliary drainage (PTHBD), and rendezvous guidewire-associated (RGA) ERCP. High rates of successful stone clearance were observed with LAERCP (1.00; 95% CI 0.99-1.00; p = 0.47), EDGE (0.97; 95% CI 0.9-1.00; p = 0.54), IGS ERCP (1.00; 95% CI 0.87-1.00), PTHBD (1.0; 95% CI 0.96-1.00), and LCBDE (0.99; 95% CI 0.93-1.00, p < 0.001). Lower rates of stone clearance were observed with BAE (61.5%; 95%CI 44.3-76.3, p = 0.188) and EGHAC (74.0%; 95% CI 42.9-91.5, p = 0.124). Relative to EDGE, LAERCP had a longer procedure duration (133.1 vs. 67.4min) but lower complication rates (12.8% vs. 24.3%). LAERCP and EDGE had high rates of success in the management of CDL post-RYGB. LAERCP had fewer complications but was associated with longer procedure times. BAE had lower success rates than both LAERCP and EDGE.

EUS-directed transgastric ERCP: a step-by-step approach (with video)

Transluminal procedures have literally revolutionized endoscopy in general and EUS specifically. One of the most valuable innovations in the past decade is the development and widespread implementation of the so-called EDGE (EUS-directed transgastric ERCP) procedure, which allows ERCP to be performed via a transluminal route in patients who have previously undergone a Roux-en-Y gastric bypass. Before EDGE, patients in this situation had to undergo either a laparoscopy-assisted ERCP (which was time and resource consuming but effective) or a balloon-assisted enteroscopy to reach the papilla (which was also time consuming and more prone to failure).

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.

Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass.

Background: Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). Furthermore, in these patients, CBDS are difficult to extract due to the altered upper gastrointestinal anatomy following GBP. The aim of the present study was to assess outcome after various management methods applied in the counties of Stockholm and Uppsala, Sweden.Methods: Data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) and the Swedish Obesity Surgery Register (SoReg) were crossmatched to identify all patients who had undergone gallstone surgery after GBP, where CBDS were found at intraoperative cholangiography, in the Stockholm and Uppsala counties 2009–2013. A retrospective review of patient records was performed for all patients identified.Results: In all, 55 patients were identified. These were managed as follows: expectancy (N = 11); transgastric ERCP (N = 2); laparoscopic choledochotomy (N = 3); open choledochotomy (N = 5); transcystic stone extraction (N = 12); and other approach (N = 13). In nine cases, data on management could not be found. There were nine cases of minor postoperative complication. No retained stones were registered. The operation time was longer for transgastric ERCP (p = 0.002), and the postoperative stay was longer following open and laparoscopic choledochotomy (p < 0.001). There was no statistically significant difference between any of the methods regarding the incidence of postoperative complications (p = 0.098).Discussion: Further development of techniques for managing CBDS discovered in patients undergoing cholecystectomy after previous GBP are needed, as well as more comparative studies with greater statistical power.

Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-guided gallbladder drainage is safe and feasible.

Video 1Single-session EDGE with ERCP and EUS gallbladder drainage.

Biliopancreatic Endoscopy in Altered Anatomy.

Background and Objectives: Anatomical post-surgical alterations of the upper gastrointestinal (GI) tract have always been challenging for performing diagnostic and therapeutic endoscopy, especially when biliopancreatic diseases are involved. Esophagectomy, gastrectomy with various reconstructions and pancreaticoduodenectomy are among the most common surgeries causing upper GI tract alterations. Technological improvements and new methods have increased the endoscopic success rate in these patients, and the literature has been rapidly increasing over the past few years. The aim of this systematic review is to identify evidence on the available biliopancreatic endoscopic techniques performed in the altered post-surgical anatomy of upper GI tract. Materials and Methods: We performed a systematic search of PubMed, MEDLINE, Cochrane Library, and SCOPUS databases. Study-level variables extracted were the last name of the first author, publication year, study design, number of patients, type of post-surgical anatomical alteration, endoscopic technique, success rate and endoscopic-related adverse events. Results: Our primary search identified 221 titles, which was expanded with studies after the citation search. The final full-text review process identified 52 articles (31 retrospective studies, 8 prospective studies and 13 case reports). We found several different techniques developed over the years for biliopancreatic diseases in altered anatomy, in order to perform both endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). They included enteroscopy-assisted ERCP (double and single balloon enteroscopy-ERCP, spiral enteroscopy-ERCP) laparoscopic assisted ERCP, EUS-Directed transgastric ERCP, EUS-directed transgastric intervention, gastric access temporary for endoscopy, and percutaneous assisted trans prosthetic endoscopic therapy. The success rate was high (most of the techniques showed a success rate over 90%) and a low rate of adverse events were reported. Conclusions: We suggest the considerationof the novel techniques when approaching patients with altered anatomy who require biliopancreatic endoscopy, focusing on the surgery type, success rate and adverse events reported in the literature.

Living on the EDGE: Canadian Experience With EUS-directed Transgastric ERCP (EDGE) in Patients With Roux-en-Y Gastric Bypass Anatomy.

IntroductionRoux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EDGE, is an endoscopic approach which involves accessing the excluded stomach to facilitate ERCP.ObjectiveThe objective of this study is to describe the results of EDGE procedures performed in Canada.MethodsData were collected from patient cases who had undergone an EDGE procedure across centers in Canada. All patients had a history of RYGB bariatric surgery. In each procedure, a 20-mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS guidance to allow access from the gastric remnant/proximal jejunum to the excluded stomach. Subsequently, during a separate procedure, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was replaced with a pigtail stent or APC was used to facilitate closure of the gastro-jejunal/gastro-gastric fistula.ResultsThe indication for EDGE in the seven included cases was for the treatment of choledocholithiasis (six) or gallstone pancreatitis (one). The technical success rate of the EDGE procedure in these cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all cases. There were no adverse events reported.ConclusionThe results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery.

Endoscopic retrograde cholangiopancreatography: Current practice and future research.

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.