Original article Clinical endoscopy| Volume 94, ISSUE 4, P727-732, October 2021

Download started.


Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration

      Background and Aims

      EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE.


      We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation.


      Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding.


      Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.

      Graphical abstract


      BAE-ERCP (balloon-assisted ERCP), EDGE (EUS-directed transgastric ERCP), LAMS (lumen-apposing metal stent), SS-EDGE (single-session EUS-directed transgastric ERCP)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kedia P.
        • Kumta N.A.
        • Widmer J.
        • et al.
        Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique.
        Endoscopy. 2015; 47 (159-16)
        • Xu M.
        • Carames C.
        • Novikov A.
        • et al.
        One-step endoscopic ultrasound-directed gastro-gastrostomy ERCP for treatment of bile leak.
        Endoscopy. 2017; 49: 715-716
        • Ligresti D.
        • Amata M.
        • Granata A.
        • et al.
        Single session EUS-guided temporary gastro-gastrostomy and ERCP following gastric bypass.
        Obes Surg. 2018; 28: 886-888
        • 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.
        Gastrointest Endosc. 2018; 88: 486-494
        • Kedia P.
        • Kumta N.
        • Sharaiha R.
        • et al.
        Bypassing the bypass: endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy.
        Gastrointest Endosc. 2014; 81: 223-224
        • Shah R.J.
        • Smolkin M.
        • Yen R.Y.
        • 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: 593-600
        • Kedia P.
        • Tyberg A.
        • Kumta N.A.
        • et al.
        EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach.
        Gastrointest Endosc. 2015; 82: 560-565
        • Wright B.E.
        • Cass O.W.
        • Freeman M.L.
        ERCP in patients with long-limb Roux-en Y gastrojejunostomy and intact papilla.
        Gastrintest Endosc. 2002; 56: 225-232
        • Gutierrez J.M.
        • Lederer H.
        • Krook J.C.
        • et al.
        Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass.
        J Gastrointest Surg. 2009; 13: 2170-2175
        • Kedia P.
        • Sharaiha R.Z.
        • Kumta N.A.
        • et al.
        Internal EUS-directed transgastric ERCP (EDGE): game over.
        Gastroenterology. 2014; 147: 566-568
        • Tyberg A.
        • Nieto J.
        • Salgado S.
        • et al.
        Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure.
        Clin Endosc. 2017; 50: 185-190
        • 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.
        Endoscopy. 2017; 49: 549-552
        • Rana F.
        • Ishtiaq M.
        • Everett S.
        • et al.
        Endoscopic-ultrasound (EUS)-directed transgastric ERCP (EDGE) procedure for the management of choledocholithiasis following Roux-en-Y gastric bypass.
        Endoscopy. 2020; 52: S124
        • Vanek P.
        • Mallery S.
        • Freeman M.
        • et al.
        Single-session endoscopic ultrasound-directed transgastric ERCP (“EDGE”) in a bariatric patient with pancreatic mass and biliary obstruction.
        Obes Surg. 2020; 30: 4681-4683
        • Irani S.
        • Yang J.
        • Khashab M.A.
        Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP.
        VideoGIE. 2018; 3: 322-324

      Linked Article

      • EUS-directed transgastric ERCP: Why so on EDGE?
        Gastrointestinal EndoscopyVol. 94Issue 6
        • Preview
          EUS-directed transgastric ERCP (EDGE) has become a viable therapeutic option in patients with Roux-en-Y gastric bypass (RYGB) anatomy, especially in patients with a history of cholecystectomy.1,2 This technique seems to have overcome the suboptimal efficacy of enteroscopy-assisted ERCP and the safety issues concerning laparoscopy-assisted ERCP, respectively.2-5
        • Full-Text
        • PDF