Clin Endosc.  2017 Mar;50(2):185-190. 10.5946/ce.2016.030.

Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure

• Tyberg A
• Nieto J
• Salgado S
• Weaver K
• Kedia P
• Sharaiha R
• Gaidhane M
• Kahaleh M

• KMID: 2383536
• DOI: http://doi.org/10.5946/ce.2016.030

Abstract

BACKGROUND/AIMS
Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Rouxen-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS.
METHODS
All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection.
RESULTS
Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg.
CONCLUSIONS
EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

Keyword

EUS-directed transgastric ERCP; Lumen-apposing metal stent; Cholangiopancreatography, endoscopic retrograde; Gastric bypass

MeSH Terms

Cholangiopancreatography, Endoscopic Retrograde*
Fistula
Gastric Bypass
Hemorrhage
Humans
Stents
Ultrasonography*

Figure

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  Fig. 1. Endoscopic ultrasound image of endoscopic ultrasound-fine needle aspiration of bypassed stomach.

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  Fig. 2. Fluoroscopic image of coiling of the wire within the bypassed stomach.

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  Fig. 3. Endoscopic ultrasound image of deployment of the lumen-apposing metal stent.

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  Fig. 4. Fluoroscopic image of balloon dilation of the lumen of the lumen-apposing metal stent.

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  Fig. 5. Endoscopic view of the lumen-apposing metal stent after deployment.

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  Fig. 6. Fluoroscopic image of endoscopic retrograde cholangiopancreatography through the deployed lumen-apposing metal stent.

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