An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy

      Background and Aims

      ERCP is challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy. EUS-guided gastrogastrostomy (GG) creation is a promising novel technique to access the excluded stomach to facilitate conventional ERCP. We aimed to compare procedural outcomes and adverse events (AEs) between EUS-guided GG-assisted ERCP (EUS-GG-ERCP) and enteroscopy-assisted ERCP (e-ERCP) in patients with RYGB.


      Patients with RYGB anatomy who underwent EUS-GG-ERCP or e-ERCP between 2014 and 2016 at 5 tertiary centers were included. The primary outcome was technical success of ERCP, defined as successful cannulation of the selected duct with successful intervention as intended. Secondary outcomes included total procedural time (in the EUS-GG group, total procedural time included EUS-GG creation plus ERCP procedure time), length of hospital stay, and rate/severity of AEs graded according to the American Society for Gastrointestinal Endoscopy lexicon.


      A total of 60 patients (mean age, 57.2 ± 13.2; 75% women) were included, of whom 30 (50%) underwent EUS-GG-ERCP and 30 (50%) underwent e-ERCP (double-balloon enteroscope ERCP, 19; single-balloon enteroscope ERCP, 11). The technical success rate was significantly higher in the EUS-GG-ERCP versus the e-ERCP group (100% vs 60.0%, P < .001). Total procedure time was significantly shorter in patients who underwent EUS-GG-ERCP (49.8 minutes vs 90.7 minutes, P < .001). Postprocedure median length of hospitalization was shorter in the EUS-GG group (1 vs 10.5 days, P = .02). Rate of AEs was similar in both groups (10% vs 6.7%, P = 1).


      EUS-GG-ERCP may be superior to e-ERCP in patients with RYGB anatomy in terms of a higher technical success and shorter procedural times and offers a similar safety profile.

      Graphical abstract


      AE (adverse event), ASGE (American Society for Gastrointestinal Endoscopy), e-ERCP (enteroscopy-assisted ERCP), EUS-GG-ERCP (EUS-guided gastrogastrostomy-assisted ERCP), GG (gastrogastrostomy), LAMS (lumen-apposing metallic stent), OTSC (over-the-scope clip), RYGB (Roux-en-Y gastric bypass)
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      Linked Article

      • ERCP in patients with Roux-en-Y gastric bypass: one size does not fit all
        Gastrointestinal EndoscopyVol. 89Issue 3
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          The study by Bukhari et al1 comparing EUS-guided gastrostomy-assisted ERCP (EUS-GG-ERCP) versus enteroscopy-assisted ERCP (e-ERCP) in patients with Roux-en-Y gastric bypass (RYGB) contributes new and important information on the care of these challenging patients. Technical success was significantly higher with EUS-GG-ERCP (100% vs 60%; P < .001), whereas procedure time and hospital stay were significantly lower. The adverse events rate was similar in the 2 groups (10% vs 6.7%; P = 1).
        • Full-Text
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      • Effective newly developed short-type double-balloon endoscope for ERCP in patients with Roux-en-Y gastric bypass
        Gastrointestinal EndoscopyVol. 89Issue 4
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          We read with interest the article by Bukhari et al1 on a comparative trial of EUS-guided gastrogastrostomy-assisted ERCP (EUS-GG-ERCP) versus enteroscopy-assisted ERCP (e-ERCP) in patients with Roux-en-Y gastric bypass (RYGB) under general anesthesia. In EUS-GG-ERCP, a duodenoscope was passed through the gastrogastrostomy (GG) created by a lumen-apposing metallic stent (LAMS) into the excluded stomach. Although the authors concluded that EUS-GG-ERCP may be superior to e-ERCP in RYGB patients, the main drawback of EUS-GG-ERCP is to require 4 procedural sessions (GG creation, ERCP, LAMS removal with GG closure, and confirmation of GG closure) in most RYGB patients.
        • Full-Text
        • PDF