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.
Methods
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.
Results
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).
Conclusions
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
Graphical Abstract
Abbreviations:
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)To read this article in full you will need to make a payment
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References
- Prevalence of childhood and adult obesity in the United States, 2011-2012.JAMA. 2014; 311: 806-814
- Management of late postoperative complications of bariatric surgery.Br J Surg. 2011; 98: 1345-1355
- Gallstone formation prophylaxis after gastric restrictive procedures for weight loss: a randomized double-blind placebo-controlled trial.Ann Surg. 2003; 238: 697-702
- ERCP with the overtube-assisted enteroscopy technique: a systematic review.Endoscopy. 2014; 46: 560-572
- ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla.Gastrointest Endosc. 2002; 56: 225-232
- 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: 593-600
- Endoscopic retrograde cholangiopancreatography in patients with roux-en-Y anatomy.J Interv Gastroenterol. 2012; 2: 78-83
- Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series.Endoscopy. 2013; 45: 671-675
- 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: 677-682
- Percutaneous gastrostomy tube placement to perform transgastrostomy endoscopic retrograde cholangiopancreaticography in patients with Roux-en-Y anatomy.Dig Dis Sci. 2011; 56: 3364-3369
- Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure.Clin Endosc. 2017; 50: 185-190
- EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach.Gastrointest Endosc. 2015; 82: 560-565
- Internal EUS-directed transgastric ERCP (EDGE): game over.Gastroenterology. 2014; 147: 566-568
- 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: 549-552
- A lexicon for endoscopic adverse events: report of an ASGE workshop.Gastrointest Endosc. 2010; 71: 446-454
- Enteroscopy.Gastrointest Endosc. 2015; 82: 975-990
- Feasibility of cap-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy.Gut Liver. 2015; 9: 109-112
- Spiral assisted ERCP is equivalent to single balloon assisted ERCP in patients with Roux-en-Y anatomy.Dig Dis Sci. 2012; 57: 1391-1398
- Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients.Gastrointest Endosc. 1998; 47: 62-67
- Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients.Gastrointest Endosc. 2012; 75: 748-756
- Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients.Endosc Int Open. 2015; 3: E458-E463
- Laparoscopic-assisted ERCP and EUS in patients with prior Roux-en-Y gastric bypass surgery: a dual-center case series experience.Surg Endosc. 2016; 30: 4647-4652
- Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients.J Gastrointest Surg. 2012; 16: 203-208
- ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery.Surg Endosc. 2013; 27: 2894-2899
- Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video).Gastrointest Endosc. 2009; 70: 1254-1259
- Single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy: getting there.Gastrointest Endosc. 2015; 82: 20-23
- Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique.Endoscopy. 2015; 47: 159-163
- Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy.Gastrointest Endosc. 2015; 82: 9-19
Article info
Publication history
Published online: May 03, 2018
Accepted:
April 24,
2018
Received:
April 14,
2017
Footnotes
DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: T. Kowalski: Consultant for Boston Scientific and Medtronic. J. Nieto: Consultant and speaker for Boston Scientific; consultant, speaker, and medical advisory board member for Medtronic. R. Kunda: Consultant, speaker, and medical advisory board member for Boston Scientific; consultant for Omega Imaging; consultant and speaker for BCM Korea and Olympus. N. Ahuja: Speaker for Medtronic. S. Irani: Consultant for Boston Scientific. Y-I Chen: Consultant for Boston Scientific. V. Kumbhari: Consultant for Boston Scientific, Reshape Life Science, Medtronic, Pentax Medical. and Apollo Endosurgery. V. Singh: Consultant for Akeca Therapeutics, AbbVie. and Ariel Precision Medicine. M. A. Khashab: Consultant for Boston Scientific, Olympus, and Medtronic; medical advisory board member for Boston Scientific and Olympus. All other authors disclosed no financial relationships relevant to this publication.
If you would like to chat with an author of this article, you may contact Dr Khashab at [email protected]
Identification
Copyright
© 2018 by the American Society for Gastrointestinal Endoscopy
ScienceDirect
Access this article on ScienceDirectLinked Article
- ERCP in patients with Roux-en-Y gastric bypass: one size does not fit allGastrointestinal EndoscopyVol. 89Issue 3
- PreviewThe 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
- Preview
- Effective newly developed short-type double-balloon endoscope for ERCP in patients with Roux-en-Y gastric bypassGastrointestinal EndoscopyVol. 89Issue 4
- PreviewWe 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
- Preview
