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EUS-directed transenteric ERCP in non–Roux-en-Y gastric bypass surgical anatomy patients (with video)

Published:January 06, 2020DOI:https://doi.org/10.1016/j.gie.2019.12.043

      Background and Aims

      Enteroscopy-assisted ERCP is challenging in patients with surgically altered upper GI anatomy. This study evaluated a novel procedure, EUS-directed transenteric ERCP (EDEE), in the de novo creation of an enteroenteric anastomosis for the performance of ERCP in non–Roux-en Y gastric bypass (RYGB) patients.

      Methods

      This was a multicenter retrospective study involving 7 centers between January 2014 and October 2018. Primary outcome was clinical success (completion of EDEE and ERCP with intended interventions), and secondary outcomes were technical success and rate/severity of adverse events.

      Results

      Eighteen patients (mean age, 63 years; 13 women) were included. The most common type of surgical anatomy was Whipple (10/18) and Roux-en-Y hepaticojejunostomy (6/18). Technical success rate of EUS-guided lumen-apposing metal stent (LAMS) placement was 100% and of ERCP was 94.44% (17/18). Fourteen patients underwent separate-session EDEE with a median of 21 days (interquartile range [IQR], 11.5-36) between the 2 procedures. Median total procedure time was 111 minutes (IQR, 81-192). Clinical success and adverse events occurred in 17 (94.4%) and 1 (5.6%; abdominal pain) patients, respectively, during a median follow-up of 88 days (IQR, 54-142).

      Conclusions

      This study suggests that EDEE using LAMSs is feasible and safe in patients with non-RYGB surgical anatomy and complex pancreaticobiliary pathologies.

      Graphical abstract

      Abbreviations:

      AE (adverse event), EDEE (EUS-directed transenteric ERCP), GJ (gastrojejunostomy), IQR (interquartile range), LAMS (lumen-apposing metal stent), PTBD (percutaneous transhepatic biliary drainage), RYGB (Roux-en Y gastric bypass), RYHJ (Roux-en-Y hepaticojejunostomy)
      ERCP is the criterion standard for the management of pancreaticobiliary disease, with rates of cannulation from 95% to 97% and of adverse events (AEs) from 2% to 15% in patients with native papilla and normal GI anatomy.
      • Talukdar R.
      Complications of ERCP.
      ,
      • Inamdar S.
      • Slattery E.
      • Sejpal D.V.
      • et al.
      Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy.
      With the changing landscape of surgical management in obesity surgery and pancreaticobiliary malignancies, there has been a rise in the number of patients with surgically altered anatomy. This poses a unique challenge for performing ERCP. Enteroscopy-assisted ERCP is traditionally used in such patients but has a suboptimal success rate of 61.7% (95% confidence interval [CI], 52.9%-70.5%) and nontrivial AE rate of 6.5% (95% CI, 4.7%-9.1%).
      • Inamdar S.
      • Slattery E.
      • Sejpal D.V.
      • et al.
      Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy.
      AEs have been attributed to challenges in reaching the papilla/anastomosis and limited available instruments to successfully perform the intended interventions.
      • Takano S.
      • Fukasawa M.
      • Shindo H.
      • et al.
      Risk factors for perforation during endoscopic retrograde cholangiopancreatography in post-reconstruction intestinal tract.
      EUS-guided biliary drainage has been used for accessing the biliary system in patients with surgically altered anatomy; however, it is considered technically challenging with a limited range of possible therapeutic interventions.
      • Shah R.M.
      • Tarnasky P.
      • Kedia P.
      A review of endoscopic ultrasound guided endoscopic retrograde cholangiopancreatography techniques in patients with surgically altered anatomy.
      ,
      • Jovani M.
      • Ichkhanian Y.
      • Vosoughi K.
      • et al.
      EUS-BD for post-surgical anatomy.
      EUS-directed transenteric ERCP (EDEE) using lumen-apposing metal stents (LAMSs) entails the creation of transgastric fistula to the excluded stomach for the management of pancreaticobiliary diseases in patients with Roux-en-Y gastric bypass (RYGB) anatomy. EDEE is associated with excellent outcomes in RYGB anatomy.
      • Bukhari M.
      • Kowalski T.
      • Nieto J.
      • et al.
      An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy.
      ,
      • Ngamruengphong S.
      • Nieto J.
      • Kunda R.
      • et al.
      Endoscopic ultrasound-guided creation of a transgastric fistula for the management of hepatobiliary disease in patients with Roux-en-Y gastric bypass.
      However, data on the use of LAMSs to facilitate ERCP in patients with surgical upper GI anatomy other than RYGB are scarce. The objective of this study was to evaluate the clinical outcomes of EDEE using LAMSs in the management of pancreaticobiliary diseases in non-RYGB anatomy.

      Methods

      This international, multicenter, retrospective study involved 7 tertiary hospitals: 6 from the United States and 1 from Europe. The study was approved by individual participating Institutional Review Boards. Consecutive patients who underwent EDEE using LAMSs between January 2014 and October 2018 were included. Patients were identified using center-specific endoscopic or billing databases. All patient information was deidentified and stored in a password-protected computer. Indications to perform EDEE were non-RYGB anatomy and failure of biliary access using standard endoscopic methods, including balloon-assisted enteroscopy and/or complex pancreaticobiliary pathologies that cannot be addressed using enteroscopes. Patients with RYGB anatomy were excluded.
      Electronic records were reviewed to capture the following variables: demographics, type of surgery performed, indication for pancreaticobiliary access, prior interventions attempted, etiology for failed attempts, route of EDEE performed (ie, gastrojejunostomy [GJ], duodenojejunostomy, jejunojejunostomy, etc), types of ERCP interventions performed, stent type, stent size, stent number, number of repeat ERCPs after the index procedure, technical success (defined as successful completion all steps of EDEE), total procedure time, time for EDEE and the subsequent ERCP, clinical success (defined as successful completion of EDEE and the intended interventions without the need for subsequent percutaneous drainage or surgery), success of stent removal, hospital length of stay, AEs graded according to the American Society for Gastrointestinal Endoscopy lexicon,
      • Cotton P.B.
      • Eisen G.M.
      • Aabakken L.
      • et al.
      A lexicon for endoscopic adverse events: report of an ASGE workshop.
      and duration of follow-up. Two cases included in the current report were previously published with the intention of describing the technique.
      • Brewer Gutierrez O.I.
      • Runge T.
      • Ichkhanian Y.
      • et al.
      Lumen-apposing metal stent for the creation of an endoscopic duodenojejunostomy to facilitate bile duct clearance following Roux-en-Y hepaticojejunostomy.
      ,
      • Bukhari M.A.
      • Brewer O.
      • Chen Y.I.
      • et al.
      Endosonography-guided alteration of upper surgical anatomy to facilitate endoscopic management of biliary cast syndrome post-liver transplantation.

      Procedure technique

      Preprocedure informed consent was obtained from all patients. Prophylactic and postprocedure antibiotics were given at the discretion of the endoscopist. Before creation of the enteroenteric anastomosis, several methods were used to aid in the sonographic localization of the pancreaticobiliary limb (Table 1). In some patients, the afferent limb was initially accessed with an enteroscope fitted with a clear cap. A mixture of saline solution, contrast, and methylene blue were used to fill the target small bowel. Alternative methods to localize and distend the small bowel included placement of a percutaneous transhepatic biliary drainage (PTBD) catheter (or use of a pre-existing catheter) or insertion of a long nasobiliary catheter for injection of saline solution and contrast. These methods allow for filling and distention of the small bowel close to the papilla/bilioenteric anastomosis, which facilitates subsequent localization under radiographic and sonographic guidance.
      Table 1Different methods used for localization of afferent loop close to the ampulla/bilioenteric anastomosis
      Method for localizing and visualizing the target small bowelNo.DetailsComment
      Enteroscopy assisted1The afferent limb is reached via an enteroscope, and solution containing mixture of saline solution, contrast, and methylene blue are injected through the scope to opacify the afferent limb.Maneuvering the enteroscope through the angulations and length of the small bowel may be technically challenging and time consuming.
      Use of nasobiliary catheter1The limb is accessed, and a long nasobiliary catheter is used to fill the afferent loop with a mixture of saline solution, contrast, and methylene blue.This method also requires reaching the afferent loop with the enteroscope with advancement of a wire and subsequent placement of a long catheter for irrigation during EDEE.
      Use of PTBD catheterThe PTBD catheter is initially placed for biliary decompression or solely for the purpose of facilitating EDEE. The afferent loop is then fluid filled and distended by injection of saline solution, contrast, and methylene blue through the PTBD catheter.After successful EDEE, the PTBD catheter can be removed (awaiting tract healing) and internal stents can be placed whenever required.
      Direct EUS puncture15The afferent limb is identified by EUS by following the hepatic duct insertion into the small bowel. This small bowel loop is punctured with a 19-gauge needle, and contrast is injected. Filling of the afferent limb (and possibly opacification of the biliary tree) confirms accessing the correct limb. This is then accessed directly with a cautery-tipped LAMS.Adequate distention of the afferent limb is crucial. Administration of an antiperistaltic agent (eg, glucagon) helps with retention of the fluid in the afferent limb.
      Through-the-scope balloon target1In this method, the afferent limb is distended with a through-the-scope balloon that is advanced over a guidewire. Inflating the balloon distends the target limb, thus allowing better visualization with EUS. The deflation of the balloon on puncturing the bowel with 19-gauge needle confirms correct positioning.This method can be used when the target bowel loop is poorly distended or its visualization is poor.
      EDEE, EUS-directed transenteric ERCP; LAMS, lumen-apposing metal stent; PTBD, percutaneous transhepatic biliary drainage.
      A linear echoendoscope was then advanced, and the distended small bowel was approached radiographically and then localized sonographically. Color Doppler US was used to identify intervening vascular structures. After careful evaluation of the intended target, the distance between the 2 luminal walls was carefully measured to be within 1 cm. At the discretion of each institution, glucagon was given to decrease peristalsis, which was repeated as needed during the procedure. The target was then punctured from the stomach, duodenum, or the jejunum using a 19-gauge needle with aspiration of blue dye confirming the correct location.
      EDEE was then performed using electrocautery-enhanced (“hot”) or non–electrocautery-enhanced (“cold”) LAMSs (AXIOS; Boston Scientific, Marlborough, Mass, USA). The stent diameters used were 15 mm or 20 mm. The type of stent was chosen at the discretion of the endoscopist and availability of stent type at the time of the procedures. The electrocautery-enhanced LAMS was advanced to the target, followed by the deployment of the distal flange and then the proximal flange under a combination of endosonographic, fluoroscopic, and direct endoscopic guidance. If a non–electrocautery-enhanced LAMS was used, the target was first punctured with a 19-gauge needle followed by coiling of a .025- or .035-inch guidewire within the target under fluoroscopic guidance followed by tract dilation and LAMS insertion. Decisions regarding stent dilation, stent anchorage, and timing of ERCP were at the discretion of the endoscopist (Fig. 1, Video 1, available online at www.giejournal.org).
      Figure thumbnail gr1
      Figure 1EUS-directed transenteric ERCP (EDEE) using a 15-mm lumen-apposing metal stent (LAMS) in an 82-year-old woman for the treatment of common bile duct stones after a Whipple procedure. A, Initially, a mixture of contrast mixed with methylene blue was injected to fill the afferent limb using an enteroscope. Then, a linear echoendoscope was used and advanced to the stomach and then the proximal efferent limb just beyond the gastrojejunal anastomosis. The fluid-filled afferent limb close to the bilioenteric anastomosis was punctured with a 19-gauge FNA needle. Aspiration of blue-tinged fluid confirmed correct positioning. B, The needle was exchanged with the electrocautery-enhanced LAMS, and under sonographic guidance the distal flange was deployed followed by the proximal flange, creating jejunojejunostomy anastomosis. C, The patient returned 1 month later for ERCP and stone removal. Endoscopic view of the proximal side of LAMS 1 month postprocedure. D, Advancement of a therapeutic upper scope through the de novo created anastomosis and accessing the biliary anastomosis. E, Cholangiography was performed and the filling defect because of the stone was noted. F, Two plastic biliary stents placed in the biliary tree. Red frame showing the LAMS.

      Endpoints

      The primary endpoint was clinical success defined as successful completion of EDEE and intended interventions and without the need for subsequent percutaneous drainage or surgery during follow-up. Secondary endpoints were rate of technical success, defined as successful completion of all the procedural steps; AEs with severity graded per the American Society for Gastrointestinal Endoscopy lexicon; stent migration; and reinterventions including the need for subsequent percutaneous drainage or surgery.

      Data management and statistical analysis

      The Johns Hopkins Hospital was the coordinating center of this multicenter study. Microsoft Excel (version 2018; Redmond, Wash, USA) was used to create the datasheet for data collection. Data entry and verification were completed by the principal investigator at each participating site. Dichotomous variables were reported as frequencies with percentages. Continuous variables were reported as mean ± standard deviation or median and interquartile range (IQR), where appropriate. The analysis was performed using STATA software version 13 (Stata Corp LLC, College Station, Tex, USA).

      Results

      Eighteen patients (age 63.1 ± 11 years, 13 women) underwent EDEE and were included. Indications for prior surgery were pancreatic cancer (9/18), liver transplant (2/18), refractory benign biliary stricture (2/18), bile duct injury (2/18), ampullary cancer (1/18), duodenal switch for obesity (1/18), and recurrent choledocholithiasis (1/18). Types of surgeries performed were Whipple (10/18), Roux-en-Y hepaticojejunostomy (6/18), Billroth II (1/18), and duodenal switch (1/18). The most common pancreaticobiliary disease necessitating ERCP was malignant biliary stricture (44.4%, 8/18), followed by biliary stones (27.8%, 5/18), benign biliary stricture (22.2%, 4/18), and retained pancreatic stent resulting in recurrent pancreatitis (5.6%, 1/18). Most cases (88.9%, 16/18) had a prior attempt to access the pancreaticobiliary region using various techniques, such as enteroscopy-assisted ERCP (n = 10), ERCP using duodenoscopes (n = 3), radiologic-guided access (n = 2), and EUS-guided biliary access (n = 1). The most common reason for failed standard pancreaticobiliary access were failed biliary cannulation (n = 4), long surgical limbs (n = 4), complex biliary pathologies such as strictures/stones (n = 4), and partial afferent limb obstruction precluding biliary access (n = 3) (Table 2, Supplementary Table 1, available online at www.giejournal.org).
      Table 2Baseline characteristics of 18 patients with surgically altered upper GI anatomy who had attempted EDEE
      ChacteristicsValue
      Age, y, mean ± standard deviation63.1 ± 11.8
      Women, %72.2 (13/18)
      Prior attempted pancreaticobiliary accessEtiology of prior failed attempts
      Enteroscopy assisted, 55.6% (10/18)Failed biliary cannulation (1)

      Afferent limb stricture (1)

      Complex biliary stricture (2)

      Long afferent limb (2)

      Long efferent limb (2)

      Gastric outlet obstruction (1)

      Stone impaction (1)
      Standard duodenoscope, 16.7% (3/18)Failed biliary cannulation (1)
      Stone impaction (1)
      Metal stent resulting in afferent limb obstruction (1)
      IR guided access, 11.1% (2/18)Failed biliary cannulation (1)
      Unclear etiology (1)
      EUS-guided biliary drainage, 5.6% (1/18) (hepaticogastrostomy)Failed biliary cannulation (1)
      No prior attempts, 11.1% (2/18)None
      Values in parentheses are n/N or n.
      IR, Interventional radiology.

      Procedure characteristics

      All 18 patients underwent successful enteroenteric anastomosis creation using LAMSs. The 15 mm × 10 mm LAMS was used in 88.9% of cases (16/18) and the 20 mm × 10 mm LAMS in 11.1% (2/18). Electrocautery-enhanced LAMSs were used in most procedures (n = 16, 88.9%). The most common approach was GJ (66.7%, 12/18), followed by duodenojejunostomy (22.2%, 4/18) and jejunojejunostomy (11.1%, 2/18). Twenty-three successful ERCP interventions were performed: 10 stent insertion/removal, 5 stone removal, 5 stricture dilation, 1 electrohydraulic lithotripsy, 1 cholangioscopy, and 1 cholangiography. Stent fixation was not performed in any of these cases, and no stent dislodgment were observed. Fourteen patients underwent separate-session EDEE with a median enteroenteric anastomosis creation and ERCP procedure times of 48 minutes (IQR, 35-116) and 44 minutes (IQR, 37-73.5), respectively. Four patients underwent same-session enteroenteric anastomosis creation and ERCP with a median procedure time of 143 minutes (IQR, 70-198). Overall, the median total procedure time was 111 minutes (IQR, 81-192) (Table 3, Supplementary Table 2, available online at www.giejournal.org).
      Table 3EUS-directed transenteric ERCP: procedural characteristics and outcomes (n = 18)
      Percent (n/N)
      EUS-guided LAMS placement
       Hot LAMS88.9 (16/18)
       Cold LAMS11.1 (2/18)
      Stent diameter
       15 mm88.9 (16/18)
       20 mm11.1 (2/18)
      Overall EUS technical success100 (18/18)
      Technical success of ERCP performed after EDEE94.4 (17/18)
      Same-session EUS and ERCP22.2 (4/18)
      Technical success of same-session EUS and ERCP100 (4/4)
      EDEE, EUS-directed transenteric ERCP; LAMS, lumen-apposing metal stent.

      Clinical endpoints

      Enteroenteric anastomosis creation was successful in all 18 cases. ERCP was successfully performed in 17 patients after creation of the enteroenteric anastomosis for an overall technical success rate of 94.4%. Clinical success was achieved in 17 of 18 patients (94.4%). The 1 case in which both clinical and technical failure occurred after EUS-guided GJ creation was because of a stricture 10 cm distal to the GJ and thus ERCP could not be completed. Eight LAMSs were successfully removed. Nine patients died with the stent in place and 1 stent remains in situ while the patient undergoes chemotherapy.
      One AE occurred, for an overall AE rate of 5.6%. The patient experienced immediate postprocedure abdominal pain, rated mild in severity, and was managed conservatively. The median length of stay was 1 day (IQR, 0-3.5). The median length of follow-up was 88 days (IQR, 54-142), and no late AEs were reported. Postprocedure reintervention was reported in 4 cases because of biliary stent occlusion. Three were managed with plastic stent replacement and 1 with dilation.

      Discussion

      Endoscopic management of pancreaticobiliary diseases in patients with surgically altered anatomy is challenging. Successfully reaching and cannulating the papilla in these patients remains a demanding task with suboptimal success rates. PTBD carries a high technical success rate, but is associated with rate of AEs ranging from 2% to 28%, depending on the etiology of pancreaticobiliary disease and the definition of AE, such as bile leak, bleeding, bile peritonitis, infection, and negative impact on patient quality of life.
      • Oh H.C.
      • Lee S.K.
      • Lee T.Y.
      • et al.
      Analysis of percutaneous transhepatic cholangioscopy-related complications and the risk factors for those complications.
      • Mudireddy P.R.
      • Sethi A.
      • Siddiqui A.A.
      • et al.
      EUS-guided drainage of postsurgical fluid collections using lumen-apposing metal stents: a multicenter study.
      • Cronin C.G.
      • Gervais D.A.
      • Castillo C.F.
      • et al.
      Interventional radiology in the management of abdominal collections after distal pancreatectomy: a retrospective review.
      • Marano I.
      • Mainenti P.P.
      • Selva G.
      • et al.
      Computerized tomography-guided drainage of postoperative abdominal fluid collections.
      • Tellez-Avila F.
      • Carmona-Aguilera G.J.
      • Valdovinos-Andraca F.
      • et al.
      Postoperative abdominal collections drainage: percutaneous versus guided by endoscopic ultrasound.
      • Azeem N.
      • Baron T.H.
      • Topazian M.D.
      • et al.
      Outcomes of endoscopic and percutaneous drainage of pancreatic fluid collections arising after pancreatic tail resection.
      Despite the absence of well-established algorithmic approaches for these patients, the current practice after failed/unfeasible standard ERCP depends on the institution and the available expertise. We follow an EUS-guided approach for management of such patients. The standard EUS-guided technique is EUS-guided biliary drainage, which has been increasingly performed at institutions with available expertise in ERCP and interventional EUS. However, EUS-guided biliary drainage is more challenging in patients with surgically altered upper GI anatomy and is not feasible at times.
      • Jovani M.
      • Ichkhanian Y.
      • Vosoughi K.
      • et al.
      EUS-BD for post-surgical anatomy.
      The extrahepatic approach (choledochoduodenostomy) and the rendezvous approach are not typically performed because of anatomic reasons. The transhepatic approach (hepaticogastrostomy or hepaticojejunostomy) may not be feasible when the intrahepatic biliary ducts are not sufficiently dilated. EDEE is a novel concept, which adds to the armamentarium of techniques that can be used to access the pancreaticobiliary region in patients with complex surgically altered anatomy. A major advantage of EDEE is that it allows a minimally invasive and purely endoscopic shortcut access to the pancreaticobiliary region and use of standard ERCP equipment and accessories. In the current study, EDEE was used for both malignant and benign indications; however, EDEE is particularly useful in patients in whom repeated access is anticipated, such as in the management of benign biliary strictures and complex stone disease.
      • Brewer Gutierrez O.I.
      • Runge T.
      • Ichkhanian Y.
      • et al.
      Lumen-apposing metal stent for the creation of an endoscopic duodenojejunostomy to facilitate bile duct clearance following Roux-en-Y hepaticojejunostomy.
      ,
      • Bukhari M.A.
      • Brewer O.
      • Chen Y.I.
      • et al.
      Endosonography-guided alteration of upper surgical anatomy to facilitate endoscopic management of biliary cast syndrome post-liver transplantation.
      In the current study, 18 patients were included with a clinical and technical success rate of 94.4%, with only 1 mild AE managed conservatively. We report that EDEE can be safely performed using a variety of access points along the upper GI tract as long as the target is within 1 cm and can be adequately distended with fluid. Furthermore, enteroenterostomy creation followed by same-session ERCP were all successfully performed with 100% clinical and technical outcomes with no reported case of LAMS displacement without the need for stent anchoring. Although we favor delaying ERCP until the enteroenteric fistula matures, our preliminary data highlight the feasibility of same-session EDEE in urgent pancreaticobiliary cases when a large-diameter LAMS is used.
      The current study introduces a novel endoscopic concept, EDEE, in the management of patients with complex non-RYGB surgical anatomy and challenging pancreaticobiliary pathologies. Nonetheless, the study has some limitations. We present preliminary data on a relatively small group of selected patients who underwent EDEE by experts; therefore, the reported results cannot be generalized. Also, this was a retrospective study, which carries inherent limitations of selection bias, variable follow-up, heterogeneity between centers, and no standardized algorithms across multiple centers. In addition, these procedures are technically challenging and were performed by dedicated therapeutic endoscopists at tertiary centers, which limits the generalizability to other centers with less expertise. This study used 1 specific type of LAMS (AXIOS), and the results cannot be generalized to other LAMSs such as the NAGI (Taewoong Medical Co Ltd, Seoul, Korea) and SPAXUS (Taewoong Medical) stents. In conclusion, in this multicenter international study, our data suggest that the creation of EUS-guided enteroenteric fistula using LAMSs followed by ERCP may be safely and effectively used by experts in the management of challenging pancreaticobiliary diseases in non-RYGB patients.

      Appendix

      Supplementary Table 1Detailed baseline characteristics of 18 patients with surgically altered upper GI anatomy who underwent EUS-directed transenteric ERCP
      Patient no.Age (63.1 ± 11.8)

      (y)
      Gender (women, 72.2%; 13/18)Indication of surgeryType of surgeryIndication of pancreatobiliary accessPrior failed managementReason for prior failed management
      165FPancreatic cancerWhippleBenign biliary strictureIR drainageFailed biliary cannulation
      253FBiliary duct injury during cholecystectomyRYHJHepatic duct stonesSingle-balloon enteroscopyFailed biliary cannulation
      383FPancreatic cancerWhippleHepatic duct stonesPediatric colonoscopeLarge stone
      443FLiver transplant for PSCRYHJCBD StonesERCPLarge stone
      565FPancreatic cancerWhippleMalignant biliary strictureNo prior attemptN/A
      657FBenign biliary stricturesRYHJBenign biliary stricture + cholangitisNo prior attemptN/A
      766FPancreatic cancerWhippleMalignant biliary strictureDuodenoscopeFailed biliary cannulation
      862FPancreatic cancerWhippleMalignant biliary strictureSingle-balloon enteroscopyAfferent limb stricture
      955FBenign biliary stricturesRYGB followed by Billroth IICBD stonesPush enteroscopyLong Roux limb
      1070FWeight loss/bariatricDuodenal switchMalignant biliary strictureSingle-balloon enteroscopyInconclusive biopsy samples
      1145FBiliary duct injury during cholecystectomyRYHJBenign biliary stricturePTCDUnclear
      1266FPancreatic cancerWhippleRetained PD stent, recurrent acute pancreatitis + cholangitisPush enteroscopyLong afferent limb
      1349MLiver transplantRYHJCBD stonesPush enteroscopyLong Roux limb
      1466MPancreatic cancerWhippleMalignant biliary stricture + cholangitisPush enteroscopyLong afferent limb
      1564MPancreatic cancerWhippleMalignant biliary stricture + cholangitisNo prior attemptAfferent limb obstruction
      1661MPancreatic cancerWhippleMalignant biliary stricturePush enteroscopyOther gastric outlet obstruction
      1783MAmpullary cancerWhippleMalignant biliary strictureSingle-balloon enteroscopyComplex stricture
      1882FOpen CBD exploration and biliary reconstruction because of numerous choledocholithiasisRYHJBenign biliary stricture + cholangitisEUS-guided hepaticogastrostomyFailed biliary cannulation
      IR, Interventional radiology; PSC, Primary sclerosing cholangitis; CBD, common bile duct; N/A, not applicable; PTCD, percutaneous transhepatic cholangiodrainage; PD, pancreatic duct; ERCP, Endoscopic retrograde cholangiopancreatography, RYGB, Roux-en Y gastric bypass; RYHJ, Roux-en-Y hepaticojejunostomy.
      Supplementary Table 2Detailed procedural characteristics of 18 patients who underwent EUS-directed transenteric ERCP
      Patient no.EUS-guided access approachStent usedSize (mm)Time of ERCPIntervention performedBalloon dilation of the deployed stentAXIOS removal postprocedure (days)
      1JJHot AXIOS15Different sessionStricture dilationStent dilatedLost to follow-up
      2DJHot AXIOS15Different sessionStricture dilationNo91
      3JJHot AXIOS15Different sessionStricture dilation, stent placement, electrohydraulic lithotripsyNo28
      4GJHot AXIOS15Different sessionStricture dilation, stone removal, cholangioscopyNo140
      5GJCold AXIOS15Single sessionStent placementStent dilatedDied
      6GJHot AXIOS15Different sessionStent placementNo81
      7GJHot AXIOS15Single sessionStent placementStent dilatedLost to follow-up
      8GJHot AXIOS15Single sessionStent placementStent dilatedLost to follow-up
      9JDHot AXIOS15Different sessionStone removalNo34
      10GJHot AXIOS15Different sessionStone removalNo40
      11DJHot AXIOS15Different sessionStricture dilation, stent placementStent dilated106
      12GJHot AXIOS20Different sessionPD stent removalNoNot removed yet
      13GJHot AXIOS15Different sessionStone removalNoNot removed yet
      14GJHot AXIOS15Different sessionStent placement, stone removalStent dilatedDied
      15GJHot AXIOS15Single sessionStent placementStent dilatedDied
      16GJHot AXIOS15Different sessionStent placementStent dilatedDied
      17GJHot AXIOS20Different sessionUnsuccessful ERCPStent dilatedDied
      18DJCold AXIOS15Different sessionCholangiogramStent dilated87
      GJ, Gastrojejunostomy; DJ, duodeno-jejunostomy; JJ, jeuno-jejunostomy; PD, Pancreatic duct; ERCP, endoscopic retrograde cholangiopancreatography.

      Supplementary data

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      Linked Article

      • EUS-guided enteroenteral bypass for transenteric ERCP: building on prior knowledge
        Gastrointestinal EndoscopyVol. 93Issue 1
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          We read with interest the article from Ichkhanian et al.1 On the basis of our experience, we fully agree that EUS-guided enteroenteral anastomosis is a safe and effective technique to gain access to the biliary tree and perform ERCP in patients with surgically altered anatomy. Indeed, the present article is not the first report of such a procedure. In 2014, Perez-Miranda et al2 reported the first EUS-guided transenteric anastomosis performed to treat a recurrent biliary malignancy in altered anatomy.
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