Comparison of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography outcomes using various technical approaches

Abstract

Background and study aims Roux-en-Y gastric bypass presents an anatomic challenge for patients needing ERCP. EUS-directed transgastric ERCP (EDGE) offers high clinical success but carries considerable risk of adverse events (AEs) with no standardized technical approach. In our study, we review the safety and efficacy of our various EDGE technical approaches. Patients and methods A retrospective single-center study of all patients who underwent EDGE procedures between February 2018 and November 2019. Primary outcomes included comparing the technical and clinical success, AEs, and lumen-apposing metal stent (LAMS) migration rates per access route (gastrogastric vs jejuno-gastric), number of procedure stages (single-stage vs two-stage), and stent size (15 mm vs 20 mm). Secondary outcomes included LAMS migration characteristics and management. Results Thirty-two EDGE procedures were performed in 29 patients, including 17 single-stage and 15 two-stage procedures, 23 gastrogastric, and nine jejuno-gastric routes, fourteen 15-mm and 17 20-mm LAMS. Overall technical and clinical success rates were 96.9 % and 87.1 %, respectively, without any significant difference between groups. The overall AE rate was (34.4 %) and was significantly lower in the 20-mm LAMS group compared to the 15-mm group (17.6 % vs 57.1 %, P = 0.03). Compared to two-stage procedures, there was no significant difference in AEs with single-stage procedures (35.3 % vs 33.3 %, P = 0.33). The LAMS migration rate was (25 %) with no significant difference between groups. Most migrations were around the index procedure and managed endoscopically (62.5 %). Conclusions EDGE offers high clinical success rates but AE rates remain significant. In our series, a 20-mm LAMS resulted in a significantly lower AE rate than the 15-mm LAMS. Large multicenter studies are recommended to identify technical factors leading to an optimal EDGE procedure.

Endoscopic-Directed Trans-Gastric Retrograde Cholangiopancreatography in Patients With Roux-en-Y gastric Bypasses

“…The clinical success rate was reported for 7 studies. 5,17,20,22,[25][26][27] No heterogeneity was detected among the studies (P = 0.912, I 2 = 0%). We used a fixed-effects model for calculation and found that the clinical success rate was 94% (95% CI: 90 to 99, I² = 0%) (Fig.…”

“…Of the remaining 53 articles, 39 were excluded because of studies with less than 10 patients, insufficient data, not being in English, patients had not undergone RYGB, or EDGE procedures had not been performed. The remaining 14 studies 3,5,[16][17][18][19][20][21][22][23][24][25][26][27] were considered eligible and subjected to further analysis. Of these, 11 were retrospective and 3 prospective cohort studies, including 5 single-center and 9 multi-center studies.…”

“…We extracted the relevant data from the included studies to derive pooled technical and clinical success rates, AE rate, and LAMS migration rate. Four of these studies provided data on AEs associated with different LAMS sizes, 3,5,20,24 6 provided data on AEs associated with different access routes, 3,5,20,21,24,27 and 3 provided data on AEs associated with different numbers of stages (1 vs. 2). 3,5,21…”

“…Four of these studies provided data on AEs associated with different LAMS sizes, 3,5,20,24 6 provided data on AEs associated with different access routes, 3,5,20,21,24,27 and 3 provided data on AEs associated with different numbers of stages (1 vs. 2). 3,5,21…”

“…There was heterogeneity among the studies (P = 0.133, I 2 = 30.5%). Exclusion of 5 low quality studies, 5,18,[25][26][27] eliminated the heterogeneity (P = 0.437, I 2 = 0%). A fixed effect model was applied to the remining studies, and it was found that the AE rate was 12% (95% CI: 9 to 15, I² = 0%) (Fig.…”