Factors predictive of persistent fistulas in EUS-Directed transgastric ERCP: A multicenter matched case-control study

Published:October 10, 2022DOI:
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      EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However widespread adoption of the technique has been limited due to concerns about the development of persistent gastrogastric (GG) or jejunogastric (JG) fistulas. GG/GJ fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management/outcomes are lacking. Aims: To assess (1) factors associated with the development of persistent fistulas; (2) technical success of endoscopic fistula closure.

      Patients and methods

      This is a case-control study involving 9 centers (8 USA, 1 Europe) from 02/2015 to 09/2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Controls were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined/graded according to ASGE lexicon.


      25 patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (controls) based on age and sex. Mean LAMS dwell time was 74.7±106.2d. Following LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 (61.3%). Primary closure of the fistula was performed in 26.7% (n=20, endoscopic suturing in 17, endoscopic tacking in 2 and over-the-scope clips + endoscopic suturing in 1). When comparing cases to controls, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the two groups (p>0.05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 d vs 48 d, p=0.02), and more patients had ≥5% total body weight gain (33.3% vs 10.3%; p=0.03). LAMS dwell time was a significant predictor of persistent fistula (OR=4.5 after >40 days in situ, p=0.01). The odds of developing a persistent fistula increased by 9.5% for every 7 days that the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 76% (n=19) with successful resolution in 14 (73.7%).


      Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which if present, can be effectively managed through endoscopic closure in most cases.


      AE (Adverse Event), LAMS (Lumen Apposing Metal Stent), ERCP (Endoscopic Retrograde Cholangiopancreatography), EDGE (Endoscopic Ultrasound Directed Transgastric ERCP), FNA (Fine needle Aspirate), FNB (Fine needle Biopsy), GI (Gastrointestinal), GG (Gastrogastrostomy), IQR (Interquartile Range), JG (Jejunogastrostomy), PB (Pancreatobiliary), PEG (Percutaneous Endoscopic Gastrostomy), OTSC (Over-the-scope clips), RYGB (Roux-en-Y Gastric Bypass), TTS (Through-the-scope clips)
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