Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure
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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 48 days. 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 182 days. 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 182 days 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.
KeywordsEndoscopic ultrasound Gastric bypass Roux-en-Y ERCP EDGE EUS-GG-ERCP
Endoscopic retrograde cholangiopancreatography
Endoscopic ultrasound-directed transgastric ERCP
Device-assisted enteroscopy ERCP
Dr. James receives research and training support by a grant from the NIH (T32DK007634). Dr. Baron has no funding.
Compliance with Ethical Standards
Endoscopy reports, medical charts, and relevant laboratory data were reviewed and recorded in accordance with Institutional Review Board protocol. For this type of study, formal consent is not required. As this was a retrospective study of previously collected data, individual informed consent does not apply.
Conflict of Interest
Dr. Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America. Dr. James has no conflicts of interest.
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