Endoscopic Ultrasound-Guided Access to the Stomach in Patients with Prior Gastric Bypass to Facilitate Endoscopic Retrograde Cholangiopancreatography
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.
KeywordsObesity 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)
Video demonstrating step by step the performance of the EDGE procedure (MP4 172164 kb)
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