EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience

      Background and Aims

      Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs.


      This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management.


      Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically.


      EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.

      Graphical abstract


      AE (adverse event), DS (dual session), EDGE (EUS-directed transgastric ERCP), EDGI (EUS-directed transgastric intervention), GG (gastrogastrostomy), JG (jejunogastrostomy), LAMS (lumen-apposing metal stent), RYGB (Roux-en-Y gastric bypass), SS (single session)
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        • Choi E.K.
        • Chiorean M.V.
        • Coté G.A.
        • et al.
        ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery.
        Surg Endosc. 2013; 27: 2894-2899
        • Csendes A.
        • Burdiles P.
        • Papapietro K.
        • et al.
        Results of gastric bypass plus resection of the distal excluded gastric segment in patients with morbid obesity.
        J Gastrointest Surg. 2005; 9: 121-131
        • 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.
        Gastrointest Endosc. 2015; 82: 9-19
        • Kuga R.
        • Safatle-Ribeiro A.V.
        • Faintuch J.
        • et al.
        Endoscopic findings in the excluded stomach after Roux-en-Y gastric bypass surgery.
        Arch Surg. 2007; 142: 942-946
        • Mahawar K.K.
        • Kumar P.
        • Parmar C.
        • et al.
        Small bowel limb lengths and Roux-en-Y gastric bypass: a systematic review.
        Obes Surg. 2016; 26: 660-671
        • Samarasena J.B.
        • Nguyen N.T.
        • Lee J.G.
        Endoscopic retrograde cholangiopancreatography in patients with roux-en-Y anatomy.
        J Intervent Gastroenterol. 2012; 2: 78-83
        • Shaikh S.H.
        • Stenz J.J.
        • McVinnie D.W.
        • et al.
        Percutaneous gastric remnant gastrostomy following Roux-en-Y gastric bypass surgery: a single tertiary center's 13-year experience.
        Abdom Radiol. 2018; 43: 1464-1471
        • Attam R.
        • Leslie D.
        • Freeman M.
        • et al.
        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
        • Watkins B.J.
        • Blackmun S.
        • Kuehner M.E.
        Gastric adenocarcinoma after Roux-en-Y gastric bypass: access and evaluation of excluded stomach.
        Surgr Obes Relat Dis. 2007; 3: 644-647
        • Tekola B.
        • Wang A.Y.
        • Ramanath M.
        • et al.
        Percutaneous gastrostomy tube placement to perform transgastrostomy endoscopic retrograde cholangiopancreaticography in patients with Roux-en-Y anatomy.
        Dig Dis Sci. 2011; 56: 3364-3369
        • Bowman E.
        • Greenberg J.
        • Garren M.
        • et al.
        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
        • Schreiner M.A.
        • Chang L.
        • Gluck M.
        • et al.
        Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients.
        Gastrointest Endosc. 2012; 75: 748-756
        • Kedia P.
        • Tarnasky P.R.
        • Nieto J.
        • et al.
        EUS-directed transgastric ERCP (EDGE) versus laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y gastric bypass (RYGB) anatomy: a multicenter early comparative experience of clinical outcomes.
        J Clin Gastroenterol. 2019; 53: 304-308
        • Kochhar G.S.
        • Mohy-Ud-Din N.
        • Grover A.
        • et al.
        EUS-directed transgastric endoscopic retrograde cholangiopancreatography versus laparoscopic-assisted ERCP versus deep enteroscopy-assisted ERCP for patients with RYGB.
        Endosc Int Open. 2020; 8: E877-E882
        • Tønnesen C.J.
        • Young J.
        • Glomsaker T.
        • et al.
        Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP after Roux-en-Y gastric bypass.
        Endoscopy. 2020; 52: 654-661
        • 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
        • Lennon A.M.
        • Kapoor S.
        • Khashab M.
        • et al.
        Spiral assisted ERCP is equivalent to single balloon assisted ERCP in patients with Roux-en-Y anatomy.
        Dig Dis Sci. 2012; 57: 1391-1398
        • 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: 159-163
        • Kedia P.
        • Sharaiha R.Z.
        • Kumta N.A.
        • et al.
        Internal EUS-directed transgastric ERCP (EDGE): game over.
        Gastroenterology. 2014; 147: 566-568
        • Dhindsa B.S.
        • Dhaliwal A.
        • Mohan B.P.
        • et al.
        EDGE in Roux-en-Y gastric bypass: How does it compare to laparoscopy-assisted and balloon enteroscopy ERCP: a systematic review and meta-analysis.
        Endosc Int Open. 2020; 8: E163-E171
        • Runge T.M.
        • Chiang A.L.
        • Kowalski T.E.
        • et al.
        Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study.
        Endoscopy. 2021; 53: 611-618
        • Prakash S.
        • Elmunzer B.J.
        • Forster E.M.
        • et al.
        Endoscopic ultrasound-directed transgastric ERCP (EDGE): a systematic review describing the outcomes, adverse events, and knowledge gaps.
        Endoscopy. 2022; 54: 52-61
        • Krafft M.R.
        • Hsueh W.
        • James T.W.
        • et al.
        The EDGI new take on EDGE: EUS-directed transgastric intervention (EDGI), other than ERCP, for Roux-en-Y gastric bypass anatomy: a multicenter study.
        Endosc Int Open. 2019; 7: E1231-E1240
        • Cotton P.B.
        • Eisen G.M.
        • Aabakken L.
        • et al.
        A lexicon for endoscopic adverse events: report of an ASGE workshop.
        Gastrointest Endosc. 2010; 71: 446-454
        • 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
        • Shinn B.
        • Boortalary T.
        • Raijman I.
        • et al.
        Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration.
        Gastrointest Endosc. 2021; 94: 727-732
        • Moran R.A.
        • Ngamruengphong S.
        • Sanaei O.
        • et al.
        EUS-directed transgastric access to the excluded stomach to facilitate pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy.
        Endosc Ultrasound. 2019; 8: 139-145
        • Krafft M.R.
        • Lorenze A.
        • Croglio M.P.
        • et al.
        "Innocent as a LAMS": Does spontaneous fistula closure (secondary intention), after EUS-directed transgastric ERCP (EDGE) via 20-mm lumen-apposing metal stent, confer an increased risk of persistent fistula and unintentional weight gain?.
        Dig Dis Sci. 2022; 67: 2337-2346