Endoscopic Ultrasound-Guided Access to the Stomach in Patients with Prior Gastric Bypass to Facilitate Endoscopic Retrograde Cholangiopancreatography

  • Christine Boumitri
  • Bhupinder Romana
  • Michel Kahaleh


Pancreatobiliary disorders are common after Roux-en-Y gastric bypass and represent a major challenge for conventional endoscopic retrograde cholangiopancreatography due to the altered anatomy and varying length of the reconstructed intestinal limbs. Device-assisted enteroscopy is often used to reach the papilla and perform ERCP in this patient population. However, this approach might be challenging due to the orientation of the papilla relative to the forward viewing endoscope and the limited accessories currently available with a reported success rate of 63% (at best). A transgastric approach has been proposed and used in these patients; however, it requires interventional radiology and surgical services and is associated with increased costs and adverse events. The evolution of endoscopic ultrasound from a diagnostic to a therapeutic tool has led to a new innovative technique where the access into the remnant stomach can be obtained with endoscopic ultrasound guidance without the need for a surgical gastrostomy or interventional radiology. Furthermore, this endoscopic ultrasound-guided approach in addition to the introduction of the lumen apposing stent has led to the description of a new technique called endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) that allows access to the excluded pancreatobiliary tree in a minimally invasive approach without the need for a percutaneous gastrostomy.


Obesity Roux-en-Y gastric bypass (RYGB) Conventional endoscopic retrograde cholangiopancreatography (ERCP) Laparoscopic-assisted ERCP Enteroscopy-assisted ERCP Gastrostomy tube Endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) 

Supplementary material

Video 14.1

Video demonstrating step by step the performance of the EDGE procedure (MP4 172164 kb)


  1. 1.
    Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in Obesity Among Adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284–91.CrossRefGoogle Scholar
  2. 2.
    Fryar CDCM, Ogden CL. Prevalence of overweight, obesity, and extreme obesity among adults aged 20 and over: United States, 1962–1962 through 2011–2014. National Center for Health Statistics Data, Health E-Stats, July 2016. Available from Scholar
  3. 3.
    Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–32.CrossRefGoogle Scholar
  4. 4.
    Choi EK, Chiorean MV, Cote GA, El H II, Ballard D, Fogel EL, et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc. 2013;27(8):2894–9.CrossRefGoogle Scholar
  5. 5.
    Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77(4):593–600.CrossRefGoogle Scholar
  6. 6.
    Maaser C, Lenze F, Bokemeyer M, Ullerich H, Domagk D, Bruewer M, et al. Double balloon enteroscopy: a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system. Am J Gastroenterol. 2008;103(4):894–900.CrossRefGoogle Scholar
  7. 7.
    Banerjee N, Parepally M, Byrne TK, Pullatt RC, Cote GA, Elmunzer BJ. Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis. 2017;13(7):1236–42.CrossRefGoogle Scholar
  8. 8.
    Attam R, Leslie D, Freeman M, Ikramuddin S, Andrade R. EUS-assisted, fluoroscopically guided gastrostomy tube placement in patients with Roux-en-Y gastric bypass: a novel technique for access to the gastric remnant. Gastrointest Endosc. 2011;74(3):677–82.CrossRefGoogle Scholar
  9. 9.
    Attam R, Leslie D, Arain MA, Freeman ML, Ikramuddin S. EUS-guided sutured gastropexy for transgastric ERCP (ESTER) in patients with Roux-en-Y gastric bypass: a novel, single-session, minimally invasive approach. Endoscopy. 2015;47(7):646–9.CrossRefGoogle Scholar
  10. 10.
    Kedia P, Kumta NA, Widmer J, Sundararajan S, Cerefice M, Gaidhane M, et al. Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique. Endoscopy. 2015;47(2):159–63.CrossRefGoogle Scholar
  11. 11.
    Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ, et al. EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc. 2015;82(3):560–5.CrossRefGoogle Scholar
  12. 12.
    Law R, Wong Kee Song LM, Petersen BT, Baron TH. Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy. 2013;45(8):671–5.CrossRefGoogle Scholar
  13. 13.
    Law R, Grimm IS, Baron TH. Modified percutaneous assisted transprosthetic endoscopic therapy for transgastric ERCP in a gastric bypass patient. Endoscopy. 2016;48(Suppl 1):E16–7.PubMedGoogle Scholar
  14. 14.
    Tyberg A, Nieto J, Salgado S, Weaver K, Kedia P, Sharaiha RZ, et al. Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc. 2017;50(2):185–90.CrossRefGoogle Scholar
  15. 15.
    Ngamruengphong S, Nieto J, Kunda R, Kumbhari V, Chen YI, Bukhari M, et al. Endoscopic ultrasound-guided creation of a transgastric fistula for the management of hepatobiliary disease in patients with Roux-en-Y gastric bypass. Endoscopy. 2017;49(6):549–52.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Christine Boumitri
    • 1
  • Bhupinder Romana
    • 1
  • Michel Kahaleh
    • 2
  1. 1.Division of Gastroenterology and HepatologyUniversity of MissouriColumbiaUSA
  2. 2.Division of Gastroenterology and HepatologyRutgers Robert Wood JohnsonNew BrunswickUSA

Personalised recommendations