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Fabbri C, Scalvini D, Paolo G, Binda C, Mauro A, Coluccio C, Mazza S, Trebbi M, Torello Viera F, Anderloni A. Complications and management of interventional endoscopic ultrasound: A critical review. Best Pract Res Clin Gastroenterol 2024; 69:101888. [PMID: 38749575 DOI: 10.1016/j.bpg.2024.101888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/30/2024] [Indexed: 07/13/2024]
Abstract
In the last decades, Endoscopic ultrasound (EUS) has rapidly grown and evolved from being mainly a diagnostic procedure, to being an interventional and therapeutic tool in several pathological clinical scenarios. With the progressive growth in technical expertise and dedicated devices, interventional endoscopic ultrasound procedures (IEUSP) have shown high rates of technical and clinical success, together with a relatively safe profile. However, the description and the standardization of different and specific types of adverse events (AEs) are still scarce in literature, and, consequently, even less the management of AEs. The aim of this study is to critical review and to describe AEs related to each of the main IEUSP, and to provide an overview on the possible management strategies of endoscopic complications. Future studies and guidelines are surely required to reach a better standardization of different AEs and their best management.
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Affiliation(s)
- Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Davide Scalvini
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Giuffrida Paolo
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy.
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Stefano Mazza
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Margherita Trebbi
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Francesca Torello Viera
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Su T, Chen T, Wang J, Feng Y, Wang R, Zhao S. Endoscopic-Directed Trans-Gastric Retrograde Cholangiopancreatography in Patients With Roux-en-Y gastric Bypasses: A Meta-Analysis. J Clin Gastroenterol 2023; 57:871-878. [PMID: 37267459 DOI: 10.1097/mcg.0000000000001864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/13/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound-directed trans-gastric retrograde cholangiopancreatography (EDGE) is a new procedure for treating pancreaticobiliary diseases in patients with Roux-en-Y gastric bypass (RYGB). The aim of this meta‑analysis was to determine the overall outcomes and safety of EDGE. MATERIALS AND METHODS We performed a computerized search of the main databases, including PubMed, EMBASE, Cochrane Library, and Science Citation Index, through October 2022. The main outcome measures examined in the meta-analysis were technical and clinical success rates and overall adverse event (AE) rate, especially the lumen-apposing metal stent (LAMS) dislodgement rate. AE rates were assessed according to LAMS size (15 vs. 20 mm), number of stages (single vs. two) and access route (gastrogastric vs. jejuno-gastric). RESULTS Fourteen trials with a total of 574 patients who had undergone 585 EDGE procedures were included in this study. The cumulative technical and clinical success and AE rates were 98%, 94%, and 14%, respectively. The commonest AE was LAMS dislodgement (rate 4%). The overall AE rate was lower in the 20-mm LAMS than in the 15-mm LAMS group (odds ratio [OR]=5.79; 95% confidence interval [CI]: 2.35 to 14.29). There were no significant differences in AE rate between number of stages (OR=1.36; 95% CI: 0.51 to 3.64) or differing access routes (OR=1.03; 95% CI 0.48 to 2.22). CONCLUSION We here provide evidence that EDGE for endoscopic retrograde cholangiopancreatography yields good treatment outcomes in patients with RYGBs. The AE rate is significantly lower with 20-mm versus 15-mm LAMS; thus, the former is likely preferable.
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Affiliation(s)
- Tong Su
- Department of Gastroenterology, Department of Infectious Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Kedia P, Shah-Khan S, Tyberg A, Gaidhane M, Sarkar A, Shahid H, Zhao E, Thakkar S, Winkie M, Krafft M, Singh S, Zolotarevsky E, Barber J, Zolotarevsky M, Greenberg I, Eke D, Lee D, Gress F, Andalib I, Bills G, Carey P, Gabr M, Lajin M, Vazquez-Sequeiros E, Pleskow D, Mehta N, Schulman A, Kwon R, Platt K, Nasr J, Kahaleh M. Endoscopic ultrasound-directed transgastric ERCP (EDGE): A multicenter US study on long-term follow-up and fistula closure. Endosc Int Open 2023; 11:E529-E537. [PMID: 37251793 PMCID: PMC10219784 DOI: 10.1055/a-2057-5984] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/09/2023] [Indexed: 05/31/2023] Open
Abstract
Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a safe and efficacious procedure to treat pancreaticobiliary diseases in Roux-en-Y gastric bypass (RYGB). This multicenter study aimed to determine the long-term outcomes of EDGE focusing on fistula persistence rates and post-procedure weight change. Patients and methods Information about patients with Roux-en-Y gastric bypass anatomy who underwent EDGE between 2015 and 2021 from 10 institutions was captured in a registry. Patient demographics, procedural details, and clinical outcomes were analyzed. Results One hundred seventy-two patients were included in the study (mean age 60, 25 % male). Technical success of lumen-apposing metal stent (LAMS) placement was 171 of 172 (99.4 %) while clinical success of intervention was 95%. The mean procedure time was 65 minutes. The most commonly reported complication was stent dislodgement/migration (n = 29, 17). Mean length of time of LAMS duration was 69 days. Mean follow-up time was 6 months. Endoscopic fistula closure was performed in 40 % of patients (69/172) at the time of LAMS removal. Persistence of fistula was observed in 19 of 62 patients (31 %) assessed. Length of LAMS indwell time (days) was a predictor of persistent fistula. The average weight gain while the LAMS was in place was 12 lb in 63 patients (36.6 %); 59.4 % of patients gained < 5 lb. Conclusions EDGE is a safe and efficacious procedure for RYGB patients requiring ERCP. Post-procedure evaluation and management of the enteral fistula varies widely among centers currently and would benefit from further standardization. Fistula persistence appears to be uncommon and can be managed endoscopically but may be related to length of indwell times of the LAMS.
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Affiliation(s)
- Prashant Kedia
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - Sardar Shah-Khan
- Rutgers Robert Wood Johnson Medical School – Gastroenterology, New Brunswick, New Jersey, United States
| | - Amy Tyberg
- Weill Cornell Medical College – Gastroenterology & Hepatology, New York, New York, United States
| | - Monica Gaidhane
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - Avik Sarkar
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - Haroon Shahid
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - Eric Zhao
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - Shyam Thakkar
- West Virginia University – Gastroenterology, New Brunswick, New Jersey, United States
| | - Mason Winkie
- West Virginia University – Gastroenterology, New Brunswick, New Jersey, United States
| | - Matthew Krafft
- Ruby Memorial Hospital – Digestive Diseases, Morgantown, West Virginia, United States
| | - Shailendra Singh
- Ruby Memorial Hospital – Digestive Diseases, Morgantown, West Virginia, United States
| | - Eugene Zolotarevsky
- Spectrum Health Butterworth Hospital – Advanced Endoscopy/Gastroenterology, Grand Rapids, Michigan, United States
| | - Jeremy Barber
- Spectrum Health Butterworth Hospital – Advanced Endoscopy/Gastroenterology, Grand Rapids, Michigan, United States
| | - Mitchelle Zolotarevsky
- Spectrum Health Butterworth Hospital – Advanced Endoscopy/Gastroenterology, Grand Rapids, Michigan, United States
| | - Ian Greenberg
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - Dhiemeziem Eke
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - David Lee
- Methodist Dallas Medical Center – Gastroenterology, Dallas, Texas, United States
| | - Frank Gress
- Icahn School of Medicine at Mount Sinai – Gastroenterology, New York, New York, United States
| | - Iman Andalib
- Robert Wood Johnson Health System – Gastroenterology, New Brunswick, New Jersey, United States
| | - Gregory Bills
- University of Kentucky Medical Center – Gastroenterology, New Brunswick, Kentucky, United States
| | - Patrick Carey
- University of Kentucky Medical Center – Gastroenterology, New Brunswick, Kentucky, United States
| | - Moamen Gabr
- Tanta University Faculty of Medicine – Gastroenterology and Hepatology – Internal Medicine, Tanta, Egypt
| | - Michael Lajin
- Sharp Grassmont Hospital – Gastroenterology/Internal Medicine, Mesa, California, United States
| | | | - Douglas Pleskow
- Beth Israel Deaconess Medical Center – Gastroenterology, Boston, Massachusetts, United States
| | - Neal Mehta
- Beth Israel Deaconess Medical Center – Gastroenterology, Boston, Massachusetts, United States
| | - Allison Schulman
- University of Michigan Medicine – Gastroenterology, New Brunswick, Michigan, United States
| | - Richard Kwon
- University of Michigan Health System – Gastroenterology, Ann Arbor, Michigan, United States
| | - Kevin Platt
- University of Michigan Michigan Medicine – Internal Medicine, Ann Arbor, Michigan, United States
| | - John Nasr
- West Virginia University – Gastroenterology, New Brunswick, New Jersey, United States
| | - Michel Kahaleh
- Rutgers Robert Wood Johnson Medical School – Gastroenterology, New Brunswick, New Jersey, United States
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Platt KD, Bhalla S, Schulman AR. Single-session EUS-guided gastrogastrostomy to facilitate cystgastrostomy in Roux-en-Y gastric bypass. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:134-136. [PMID: 36935807 PMCID: PMC10019982 DOI: 10.1016/j.vgie.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Video 1Single-session EUS-guided gastrogastrostomy creation to facilitate cystgastrostomy in Roux-en-Y gastric bypass.
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Affiliation(s)
- Kevin D Platt
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Sean Bhalla
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Allison R Schulman
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Reduction of Lams-Related Adverse Events with Accumulating Experience in a Large-Volume Tertiary Referral Center. J Clin Med 2023; 12:jcm12031037. [PMID: 36769683 PMCID: PMC9917779 DOI: 10.3390/jcm12031037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND AIMS Lumen-apposing metal stents (LAMSs) are increasingly used both for on- and off-label indications. We continuously adapt our step-by-step protocol to optimize the safe deployment of LAMSs for the different indications. The aim of this study was to evaluate the impact of this approach over time. METHODS We conducted a single-center study on consecutive patients who underwent LAMS placement for on- and off-label indications between June 2020 and June 2022. Endpoints included technical success, clinical success and adverse event rates. We compared the results with our previously published early experience with LAMSs (N = 61), between March 2018 and May 2020. RESULTS This cohort consisted of 168 LAMSs in 153 patients. Almost half of them (47.6%) were placed for off-label indications (gastro-enterostomy, temporary access to the excluded stomach in patients with previous gastric bypass, drainage of postsurgical collections, stenting of short refractory gastrointestinal strictures). While the technical and clinical success rates were similar to those in our previously published cohort (97% and 93.5% versus 93.4% and 88.5%, respectively), the adverse event rate dropped from 21.3% to 8.9%. CONCLUSIONS Our results demonstrate the impact of a learning curve in LAMS placement, with a clinically relevant drop in LAMS-related adverse events over time.
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Yi H, Liu Q, He S, Zhong L, Wu SH, Guo XD, Ning B. Current uses of electro-cautery lumen apposing metal stents in endoscopic ultrasound guided interventions. Front Med (Lausanne) 2022; 9:1002031. [PMID: 36530880 PMCID: PMC9747751 DOI: 10.3389/fmed.2022.1002031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/11/2022] [Indexed: 09/10/2023] Open
Abstract
The electro-cautery lumen apposing metal stent (EC-LAMS) is a newly developed device that integrates the electro-cautery cyctotome with the one-step metal stent delivery and releasing system in recent years. LAMS was first designed to complete the drainage of pancreatic fluid collection under endoscopic ultrasound guidance, and the technological innovation of EC-LAMS has made more off-labeled indications of endoscopic intervention for gastrointestinal diseases realized, such as abdominal fluid drainage, bile duct, or gallbladder drainage through stomach or duodenum, gastrointestinal anastomosis, and the establishment of fistulous channel for further endoscopic operation when necessary. The unique feature of this metal stent is that it has the design of a saddle shape and a large lumen, and can almost connect the adjacent structures to minimize the risk of perforation and leakage. Compared with traditional LAMS, EC-LAMS, an advanced integrated device, can greatly simplify the endoscopic process, shorten the procedure time and reduce the technical difficulty, thus it can help endoscopists complete more complex endoscopic interventions. In this review, we discuss the state of art with regard to EC-LAMS and its endoscopic process, current indications, outcomes, adverse events, and future application prospects.
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Affiliation(s)
- Hang Yi
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Liu
- Department of Gastroenterology, Chongqing General Hospital, Chongqing, China
| | - Song He
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Zhong
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su-hua Wu
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-dong Guo
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Ning
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Elfert K, Zeid E, Duarte-Chavez R, Kahaleh M. Endoscopic ultrasound guided access procedures following surgery. Best Pract Res Clin Gastroenterol 2022; 60-61:101812. [PMID: 36577531 DOI: 10.1016/j.bpg.2022.101812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/13/2022] [Indexed: 11/17/2022]
Abstract
EUS-guided therapeutic procedures have emerged in the recent years as a minimally invasive option for the management of complex hepatobiliary disorders. Gastrointestinal surgeries, e.g., pancreaticoduodenectomy, Roux-en-Y Gastric Bypass, Roux-en-Y hepaticojejunostomy, and partial gastrectomy with different reconstructions are commonly performed for a wide range of indications that include tumour resections and weight loss. Conventional endoscopic procedures are challenging in those patients due to inaccessible or unreachable ampulla. Patients with surgically altered anatomy are good candidates for EUS-guided access procedures that have shown good technical and clinical success rates. This category of procedures includes EUS-guided biliary drainage, EUS-guided pancreatic drainage, EUS-directed transgastric ERCP (EDGE) and EUS-guided Gastroenterostomy. Studies have shown that these procedures have comparable or better results than traditional endoscopic, interventional radiology-guided and surgical procedures. This article discusses the indications, technique and outcome of the different EUS-guided access procedures in patients with surgically altered anatomy.
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Affiliation(s)
- Khaled Elfert
- Department of Medicine, SBH Health System, Bronx, NY, USA.
| | - Ebrahim Zeid
- Department of Surgery, Kafr El Zayat General Hospital, Kafr EL Zayat, Gharbiyah, Egypt.
| | - Rodrigo Duarte-Chavez
- Gastroenterology Division, Department of Medicine, St Luke's University Health Network, Bethlehem, PA, USA.
| | - Michel Kahaleh
- Gastroenterology Division, Department of Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
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Honda H, Mosko JD, Kobayashi R, Fecso A, Kim BS, Scott S, May GR. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography for patients with Roux-en-Y gastric bypass anatomy: technical overview. Clin Endosc 2022; 55:736-741. [PMID: 36464820 PMCID: PMC9726442 DOI: 10.5946/ce.2022.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass anatomy is a well-documented challenge. Traditionally, this problem has been overcome with adjunctive techniques, such as device-assisted ERCP, including double-balloon or single-balloon enteroscopy and laparoscopy-assisted transgastric ERCP. Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a novel technique that enables access to the ampulla using a duodenoscope without surgical intervention and has shown high clinical and technical success rates in recent studies. However, this approach is technically demanding, necessitating a thorough understanding of the gastrointestinal anatomy as well as high operator experience. In this review, we provide a technical overview of EDGE in parallel with our personal experience at our center and propose a simple algorithm to select patients for its appropriate application. In conjunction, the outcomes of EDGE compared with those of device-assisted and laparoscopy-assisted transgastric ERCP will be discussed.
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Affiliation(s)
- Hirokazu Honda
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Jeffrey D. Mosko
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Ryosuke Kobayashi
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Andras Fecso
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Bong Sik Kim
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Schoeman Scott
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Gary R. May
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada,Correspondence: Gary R. May The Centre for Therapeutic Endoscopy and Endoscopic Oncology and Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada E-mail:
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Connell M, Sun WYL, Mocanu V, Dang JT, Kung JY, Switzer NJ, Birch DW, Karmali S. Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis. Surg Endosc 2022; 36:6868-6877. [PMID: 35041054 DOI: 10.1007/s00464-022-09018-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Several therapeutic modalities have been proposed for the management of choledocholithiasis (CDL) following Roux-en-Y gastric bypass (RYGB), yet debate exists regarding the optimal management. The purpose of our study was to review the current literature to compare the efficacy of various techniques in the management of CDL post-RYGB. METHODS A comprehensive search of multiple databases was conducted. Studies reporting on the management of CDL in patients post-RYGB and including at least 5 patients were eligible for inclusion. The primary outcome was successful stone clearance. Secondary outcomes included procedure duration, length of hospital stay, and adverse events. RESULTS Of 3259 identified studies, 53 studies involving 857 patients were included in the final analysis. The mean age was 54.4 years (SD 7.05), 78.8% were female (SD 13.6%), and the average BMI was 30.8 kg/m2 (SD 6.85). Procedures described included laparoscopy-assisted ERCP (LAERCP), balloon-assisted enteroscopy (BAE), ultrasound-directed transgastric ERCP (EDGE), laparoscopic common bile duct exploration (LCBDE), EUS-guided intra-hepatic puncture with antegrade clearance (EGHAC), percutaneous trans-hepatic biliary drainage (PTHBD), and rendezvous guidewire-associated (RGA) ERCP. High rates of successful stone clearance were observed with LAERCP (1.00; 95% CI 0.99-1.00; p = 0.47), EDGE (0.97; 95% CI 0.9-1.00; p = 0.54), IGS ERCP (1.00; 95% CI 0.87-1.00), PTHBD (1.0; 95% CI 0.96-1.00), and LCBDE (0.99; 95% CI 0.93-1.00, p < 0.001). Lower rates of stone clearance were observed with BAE (61.5%; 95%CI 44.3-76.3, p = 0.188) and EGHAC (74.0%; 95% CI 42.9-91.5, p = 0.124). Relative to EDGE, LAERCP had a longer procedure duration (133.1 vs. 67.4 min) but lower complication rates (12.8% vs. 24.3%). CONCLUSION LAERCP and EDGE had high rates of success in the management of CDL post-RYGB. LAERCP had fewer complications but was associated with longer procedure times. BAE had lower success rates than both LAERCP and EDGE.
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Affiliation(s)
- Matthew Connell
- Division of General Surgery, University of Alberta, Edmonton, AB, Canada
| | - Warren Y L Sun
- Division of General Surgery, University of Alberta, Edmonton, AB, Canada.
| | - Valentin Mocanu
- Division of General Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jerry T Dang
- Division of General Surgery, University of Alberta, Edmonton, AB, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Noah J Switzer
- Division of General Surgery, University of Alberta, Edmonton, AB, Canada
| | - Daniel W Birch
- Division of General Surgery, University of Alberta, Edmonton, AB, Canada
| | - Shahzeer Karmali
- Division of General Surgery, University of Alberta, Edmonton, AB, Canada
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Shah-Khan SM, Zhao E, Tyberg A, Sarkar S, Shahid HM, Duarte-Chavez R, Gaidhane M, Kahaleh M. Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE) Utilization of Trends Among Interventional Endoscopists. Dig Dis Sci 2022; 68:1167-1177. [PMID: 35947304 DOI: 10.1007/s10620-022-07650-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Endoscopic ultrasound-directed transgastric ERCP (EDGE) has become standard-of-care therapy at many centers for pancreaticobiliary disease in patients with Roux-en-Y Gastric Bypass. In this study, we aimed to evaluate the opinions and practices of endoscopists who perform EDGE. METHODS A 22-question utilization of EDGE survey was sent to 36 advanced endoscopists at tertiary care centers in the United States. The two-section survey included questions regarding advanced endoscopy volume and training at the respective facilities, and questions on specific details of EDGE utilization. RESULTS Among 36 interventional endoscopists (IE) surveyed, 14 (39%) reported performing > 1000 ERCPs annually. Thirty (83%) offered EDGE as an option for Roux-en-Y gastric bypass patients with previous cholecystectomy. Other options offered included: 19 (53%) offered Laparoscopy-assisted ERCP (LA-ERCP), 7 (19%) offered Single-Balloon ERCP (SBE), and 10 (28%) offered percutaneous drainage (PTC). Twenty (56%) IE performed 10 or less EDGE procedures, while 16 (44%) performed 11 or more. Single-session EDGE was performed by 7 (19%) IE, while 15 (42%) performed dual session, and 13 (36%) performed both. 19 (53%) actively closed fistulas while 17 (47%) let them close spontaneously. Thirty one (86%) reported a technical success rate of 91% to 100%. The most frequently reported immediate adverse event post-procedurally was abdominal pain, reported by 17 IE (47%). Weight gain was reported by 2 IE (6%). CONCLUSION EDGE continues to gain in popularity as an option for Roux-en-Y gastric bypass patients requiring pancreaticobiliary interventions, with 24/36 IE (67%) believing that it should be the new standard. In addition, most report a low frequency of post-procedural weight gain. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05041608.
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Affiliation(s)
- Sardar M Shah-Khan
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Eric Zhao
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Amy Tyberg
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Sardar Sarkar
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Haroon M Shahid
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Rodrigo Duarte-Chavez
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Monica Gaidhane
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, NJ, 08901, USA.
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Krafft MR, Lorenze A, Croglio MP, Fang W, Baron TH, Nasr JY. "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. [PMID: 34189668 PMCID: PMC8714861 DOI: 10.1007/s10620-021-07003-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/14/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Persistent gastrogastric or jejunogastric fistula is theoretically a concerning sequela of EUS-directed transgastric ERCP/EUS (EDGE), as it may functionally reverse the malabsorptive mechanism of Roux-en-Y gastric bypass (RYGB). Prior EDGE studies, using predominantly 15-mm (diameter) lumen-apposing metal stents (LAMS) and fistula closure by primary intent, collectively report 9% persistent fistula rate, without a clear weight gain association. Our study determines the incidence of persistent fistula, and its association with unintentional weight gain, among recipients of EDGE via 20-mm LAMS followed by spontaneous fistula closure (secondary intent). METHODS We conducted a dual-center prospective cohort study of 22 RYGB patients who underwent EDGE using 20-mm between 3/2018 and 10/2019. After LAMS extraction, all GGFs/JGFs were allowed to heal spontaneously. Objective testing for persistent fistula and total body weight (TBW) occurred a minimum of 8 weeks after LAMS extraction. RESULTS Persistent fistula was identified in 9 patients (41%). Longer LAMS dwell time (median 77-days) was observed in the persistent fistula group, compared to those with durable spontaneous fistula closure (median 35-days) (p = 0.03). Weight gain of ≥ 5% TBW occurred in 56% (n = 5) of patients with persistent fistula, compared to 15% (n = 2) of patients with spontaneous fistula closure (p = 0.128). Four patients with symptomatic persistent fistulas underwent attempted endoscopic fistula closure a median 7.5 months after LAMS extraction. Durable fistula closure occurred in the single patient who received argon plasma coagulation plus endoscopic suturing, whereas fistula dehiscence occurred in 3/3 (100%) patients with endoscopic suturing monotherapy. CONCLUSIONS Larger LAMS diameter (20-mm), longer LAMS dwell time, and spontaneous fistula closure may be technical factors that increase the likelihood of post-EDGE persistent fistula. Post-EDGE persistent fistula has not been shown by ours or other studies to be significantly associated with unintentional weight gain; however, this may be due to small sample size. We question the utility of routine fistula closure by primary intent and suggest a personalized approach to post-EDGE fistula management.
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Affiliation(s)
- Matthew Richard Krafft
- Division of Gastroenterology and Hepatology, West Virginia University School of Medicine, One Medical Center Driver, PO Box 9161, Morgantown, WV 26506-9161, USA
| | - Alyssa Lorenze
- Division of Gastroenterology and Hepatology, West Virginia University School of Medicine, One Medical Center Driver, PO Box 9161, Morgantown, WV 26506-9161, USA
| | - Michael P. Croglio
- Division of Gastroenterology and Hepatology, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - John Y. Nasr
- Division of Gastroenterology, Wheeling Hospital, Wheeling, WV, USA
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12
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Sundaram S, Mane K, Tyagi U, Jain AK, Chhanchure U, Patil P, Mehta S. Endoscopic retrieval of a blocked double-pigtail plastic biliary stent through an endoscopic ultrasound-guided gastrojejunostomy in a patient with gastric outlet obstruction. Endoscopy 2022; 54:E806-E807. [PMID: 35523222 PMCID: PMC9735287 DOI: 10.1055/a-1824-4786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Kiran Mane
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Unique Tyagi
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Aadish Kumar Jain
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Utkarsh Chhanchure
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Prachi Patil
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Shaesta Mehta
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
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13
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McCarty TR, Kumar N. Revision Bariatric Procedures and Management of Complications from Bariatric Surgery. Dig Dis Sci 2022; 67:1688-1701. [PMID: 35347535 DOI: 10.1007/s10620-022-07397-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
Abstract
Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Nitin Kumar
- HSHS Medical Group, Springfield, IL, 62704, USA.
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14
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McCarty TR, Thompson CC. Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy. Dig Dis Sci 2022; 67:1660-1673. [PMID: 35430698 DOI: 10.1007/s10620-022-07426-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 12/09/2022]
Abstract
The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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15
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Abstract
The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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16
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Abstract
Pancreaticobiliary (PB) endotherapy continues to progress in the era of therapeutic endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary method for PB access in native and altered anatomy. In altered anatomy, PB access can be obtained via enteroscopy-assisted ERCP (e-ERCP) or laparoscopy-assisted ERCP; however, both approaches have significant limitations. Endoscopic ultrasound-guided biliary and pancreatic duct drainage (EUS-BPD) are increasingly becoming the preferred alternative when ERCP fails, with advantages over percutaneous drainage. EUS-BPD continues to evolve with better feasibility, safety and efficacy as dedicated procedural equipment continues to improve. In this article, we discuss the role of endoscopic ultrasound (EUS) when ERCP fails and their indications, technique, and outcomes.
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17
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Duarte-Chavez R, Kahaleh M. Therapeutic endoscopic ultrasound. Transl Gastroenterol Hepatol 2022; 7:20. [PMID: 35548470 PMCID: PMC9081917 DOI: 10.21037/tgh-2020-12] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/12/2020] [Indexed: 08/30/2023] Open
Abstract
Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.
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Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Internal Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA
| | - Michel Kahaleh
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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18
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van Wanrooij RLJ, Bronswijk M, Kunda R, Everett SM, Lakhtakia S, Rimbas M, Hucl T, Badaoui A, Law R, Arcidiacono PG, Larghi A, Giovannini M, Khashab MA, Binmoeller KF, Barthet M, Pérez-Miranda M, van Hooft JE, van der Merwe SW. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2022; 54:310-332. [PMID: 35114696 DOI: 10.1055/a-1738-6780] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends a prolonged course of a prophylactic broad-spectrum antibiotic in patients with ascites who are undergoing therapeutic endoscopic ultrasound (EUS) procedures.Strong recommendation, low quality evidence. 2: ESGE recommends placement of partially or fully covered self-expandable metal stents during EUS-guided hepaticogastrostomy for biliary drainage in malignant disease.Strong recommendation, moderate quality evidence. 3: ESGE recommends EUS-guided pancreatic duct (PD) drainage should only be performed in high volume expert centers, owing to the complexity of this technique and the high risk of adverse events.Strong recommendation, low quality evidence. 4: ESGE recommends a stepwise approach to EUS-guided PD drainage in patients with favorable anatomy, starting with rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP), followed by antegrade or transmural drainage only when RV-ERP fails or is not feasible.Strong recommendation, low quality evidence. 5: ESGE suggests performing transduodenal EUS-guided gallbladder drainage with a lumen-apposing metal stent (LAMS), rather than using the transgastric route, as this may reduce the risk of stent dysfunction.Weak recommendation, low quality evidence. 6: ESGE recommends using saline instillation for small-bowel distension during EUS-guided gastroenterostomy.Strong recommendation, low quality evidence. 7: ESGE recommends the use of saline instillation with a 19G needle and an electrocautery-enhanced LAMS for EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedures.Strong recommendation, low quality evidence. 8: ESGE recommends the use of either 15- or 20-mm LAMSs for EDGE, with a preference for 20-mm LAMSs when considering a same-session ERCP.Strong recommendation, low quality evidence.
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Affiliation(s)
- Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, The Netherlands
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, and Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Simon M Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology Hospitals, Gachibowli, Hyderabad, India
| | - Mihai Rimbas
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Abdenor Badaoui
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Ryan Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Marc Giovannini
- Paoli-Calmettes Institute, Department of Gastrointestinal Disease, Marseille, France
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Marc Barthet
- Department of Gastroenterology, Aix-Marseille Université, APHM, Hôpital Nord, Marseille, France
| | - Manuel Pérez-Miranda
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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19
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van der Merwe SW, van Wanrooij RLJ, Bronswijk M, Everett S, Lakhtakia S, Rimbas M, Hucl T, Kunda R, Badaoui A, Law R, Arcidiacono PG, Larghi A, Giovannini M, Khashab MA, Binmoeller KF, Barthet M, Perez-Miranda M, van Hooft JE. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:185-205. [PMID: 34937098 DOI: 10.1055/a-1717-1391] [Citation(s) in RCA: 167] [Impact Index Per Article: 83.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.
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Affiliation(s)
- Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, The Netherlands
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology Hospitals, Gachibowli, Hyderabad, India
| | - Mihai Rimbas
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, and Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Abdenor Badaoui
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Ryan Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paolo G Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training (CERTT), Catholic University, Rome, Italy
| | - Marc Giovannini
- Paoli-Calmettes Institute, Department of Gastrointestinal Disease, Marseille, France
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Marc Barthet
- Department of Gastroenterology, Aix-Marseille Université, APHM, Hôpital Nord, Marseille, France
| | - Manuel Perez-Miranda
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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20
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Affiliation(s)
- Prashant Kedia
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas, USA
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21
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Prakash S, Elmunzer BJ, Forster EM, Cote GA, Moran RA. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a systematic review describing the outcomes, adverse events, and knowledge gaps. Endoscopy 2022; 54:52-61. [PMID: 33506456 PMCID: PMC8783372 DOI: 10.1055/a-1376-2394] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND : Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has emerged as a viable completely endoscopic method for performing pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. The aims of this systematic review were: (1) to describe the indications, outcomes, and complications of EDGE; and (2) to identify deficiencies in our knowledge of important technical approaches and clinical outcomes. METHODS : A systematic review was conducted via comprehensive searches of Medline, Scopus, CINAHL, and Cochrane to identify studies focusing on EDGE outcomes. Simple descriptive statistics were derived from case series only. Case reports were only included to qualitatively describe additional indications, techniques, and adverse events. RESULTS : The initial search identified 2143 abstracts. Nine case series and eight case reports were included. In the nine case series, 169 patients underwent EDGE. The technical success rate was 99 % (168 /169) for gastrogastrostomy/jejunogastrostomy creation and 98 % (166 /169) for subsequent ERCP. Minor adverse events specifically related to EDGE occurred in 18 % (31/169) and included intraprocedural stent migration/malposition (n = 27) and abdominal pain (n = 4). Moderate adverse events specific to EDGE occurred in 5 % (9/169): including bleeding (2 %), persistent fistula (1 %), and perforation (1 %). Severe adverse events occurred in one patient with a perforation requiring surgery. Deficiency in reporting on the clinical significance of adverse events was identified. CONCLUSION : Based on limited observational data, in expert hands, EDGE has a high rate of technical success and an acceptable rate of adverse events. As a novel procedure, many knowledge gaps need to be addressed to inform the design of meaningful comparative studies and guide informed consent.
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Affiliation(s)
- Shaurya Prakash
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - B. Joseph Elmunzer
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Erin M. Forster
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A. Cote
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert A. Moran
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
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22
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Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-guided gallbladder drainage is safe and feasible. VideoGIE 2021; 6:509-511. [PMID: 34765845 PMCID: PMC8573714 DOI: 10.1016/j.vgie.2021.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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23
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Fabbri C, Coluccio C, Binda C, Fugazza A, Anderloni A, Tarantino I. Lumen-apposing metal stents: How far are we from standardization? An Italian survey. Endosc Ultrasound 2021; 11:59-67. [PMID: 34677143 PMCID: PMC8887041 DOI: 10.4103/eus-d-21-00015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background and Objectives: EUS-guided transluminal drainage has increasingly developed, especially after the era of lumen-apposing metal stent (LAMS): a fully covered, barbell-shaped, metal stent with anti-migratory properties allowing direct therapeutic interventions through a wide and short channel. The aim of this survey is to investigate the current management of patients undergoing LAMS placement nationwide. Materials and Methods: Forty-eight questions were submitted to Italian centers about expertise, peri- and intra-procedural aspects, budget/refund, and future perspectives. Statistical analyzer was SPSS®. Results: Thirty-six centers completed the survey. Indications for LAMS positioning are pancreatic fluid collection drainage (PFCD, 97.2%), biliary drainage (BD, 80.5%), gallbladder drainage (GBD, 75%), and gastroentero-anastomosis (GEA, 19.4%). A total of 77.7% of the endoscopists perform only on-label procedures and 22.2% both on-label and off-label. 38.8% attended a training preliminary course, 27.7% were just supported by an expert, 22.2% had both the opportunities, and 8.3% none of them. Management of antiplatelets and sedation protocol is very heterogeneous. Only 50% involves a multidisciplinary meeting and 30.5% has a specialized clinic for follow-up. Acid suppression is usually continued after PFCD. The type and timing of postprocedural imaging varies widely. 8.3% of the endoscopists work without fluoroscopy. Refund for LAMS is mostly not guaranteed. Main future growing indications appear to be BD, GBD, and GEA (69.4%, 55.5%, and 55.5%, respectively). Conclusions: This is the first survey assessing the state of the art on LAMS almost 10 years after their advent. There are currently wide variations in practice nationwide, which demonstrates a pressing need to define technical, qualitative, and peri-procedural requirements to carry out this procedure, toward a standardization.
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Affiliation(s)
- Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì Cesena Hospitals, AUSL Romagna, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì Cesena Hospitals, AUSL Romagna, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì Cesena Hospitals, AUSL Romagna, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, via Manzoni, Rozzano (MI), Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, via Manzoni, Rozzano (MI), Italy
| | - Ilaria Tarantino
- Department of Diagnostic and Therapeutic Services, Endoscopy Service, IRCCS-ISMETT, Palermo, Italy
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24
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Papasavas P, Docimo S, Oviedo RJ, Eisenberg D. Biliopancreatic access following anatomy-altering bariatric surgery: a literature review. Surg Obes Relat Dis 2021; 18:21-34. [PMID: 34688572 DOI: 10.1016/j.soard.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/19/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Pavlos Papasavas
- Division of Metabolic and Bariatric Surgery, Hartford Hospital, Hartford, Connecticut.
| | - Salvatore Docimo
- Division of Bariatric, Foregut, and Advanced GI Surgery, Stony Brook Medicine, Stony Brook, New York
| | | | - Dan Eisenberg
- Department of Surgery, Stanford University and Palo Alto VA Health Care Center, Palo Alto, California
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Tarantino I, Rizzo GEM. Biliopancreatic Endoscopy in Altered Anatomy. MEDICINA-LITHUANIA 2021; 57:medicina57101014. [PMID: 34684051 PMCID: PMC8537222 DOI: 10.3390/medicina57101014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/17/2021] [Accepted: 09/22/2021] [Indexed: 12/31/2022]
Abstract
Background and Objectives: Anatomical post-surgical alterations of the upper gastrointestinal (GI) tract have always been challenging for performing diagnostic and therapeutic endoscopy, especially when biliopancreatic diseases are involved. Esophagectomy, gastrectomy with various reconstructions and pancreaticoduodenectomy are among the most common surgeries causing upper GI tract alterations. Technological improvements and new methods have increased the endoscopic success rate in these patients, and the literature has been rapidly increasing over the past few years. The aim of this systematic review is to identify evidence on the available biliopancreatic endoscopic techniques performed in the altered post-surgical anatomy of upper GI tract. Materials and Methods: We performed a systematic search of PubMed, MEDLINE, Cochrane Library, and SCOPUS databases. Study-level variables extracted were the last name of the first author, publication year, study design, number of patients, type of post-surgical anatomical alteration, endoscopic technique, success rate and endoscopic-related adverse events. Results: Our primary search identified 221 titles, which was expanded with studies after the citation search. The final full-text review process identified 52 articles (31 retrospective studies, 8 prospective studies and 13 case reports). We found several different techniques developed over the years for biliopancreatic diseases in altered anatomy, in order to perform both endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). They included enteroscopy-assisted ERCP (double and single balloon enteroscopy-ERCP, spiral enteroscopy-ERCP) laparoscopic assisted ERCP, EUS-Directed transgastric ERCP, EUS-directed transgastric intervention, gastric access temporary for endoscopy, and percutaneous assisted trans prosthetic endoscopic therapy. The success rate was high (most of the techniques showed a success rate over 90%) and a low rate of adverse events were reported. Conclusions: We suggest the considerationof the novel techniques when approaching patients with altered anatomy who require biliopancreatic endoscopy, focusing on the surgery type, success rate and adverse events reported in the literature.
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Affiliation(s)
- Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, 90127 Palermo, Italy;
- Correspondence:
| | - Giacomo Emanuele Maria Rizzo
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, 90127 Palermo, Italy;
- Section of Gastroenterology & Hepatology, Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90133 Palermo, Italy
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Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm. Obes Surg 2021; 31:4993-5004. [PMID: 34350533 DOI: 10.1007/s11695-021-05627-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 01/22/2023]
Abstract
Choledocholithiasis in post-surgical bariatric Roux-en-Y gastric bypass patients presents a significant challenge secondary to altered anatomy. We aim to review the existing management options including either endoscopic, surgical, percutaneous or hybrid means. Current literature suggests reasonably successful cannulation rates for single- or double-balloon ERCP ranging from 50 to 70% and 63-83%, respectively. The hybrid technique of laparoscopic transgastric ERCP has gained popularity with success rates ranging from 90 to 100%. Conventional laparoscopic techniques like transcystic duct and transcholedochal bile duct exploration are still useful options (i.e. high success rates of 81-100% and 83-96%, respectively). The role of percutaneous transhepatic choledochography remains limited although it can help with rapid bile duct decompression. If feasible, treatment pathways should progress from least to more invasive options as required.
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Khara HS, Parvataneni S, Park S, Choi J, Kothari TH, Kothari ST. Review of ERCP Techniques in Roux-en-Y Gastric Bypass Patients: Highlight on the Novel EUS-Directed Transgastric ERCP (EGDE) Technique. Curr Gastroenterol Rep 2021; 23:10. [PMID: 34212281 PMCID: PMC8249251 DOI: 10.1007/s11894-021-00808-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Hepatobiliary complications are common in Roux-en-Y gastric bypass (RYGB) patients. Despite development of multiple surgical and endoscopic access techniques over the years, ERCP using standard duodenoscope remains challenging in these patients due to the altered anatomy. RECENT FINDINGS Limited success with enteroscope-assisted and laparoscope-assisted ERCP led to the evolution of the novel EUS-directed transgastric ERCP (EDGE) procedure, with variations of this technique termed as Gastric Access Temporary for Endoscopy (GATE), EUS-guided TransGastric ERCP (EUS-TG-ERCP), EUS-guided GastroGastrostomy-assisted ERCP (EUS-GG-ERCP), and EUS-directed transgastric intervention (EDGI). EDGE has high technical (100%) and clinical success rates (60-100%), lower adverse event rate (1.5-7.6%), and up to 20% access stent migration rate; without any significant weight changes. EDGE has significantly shorter procedure time (73vs184min), post-procedural hospital stays (0.8vs2.65 days) and is more cost effective compared to other modalities. EDGE technique addresses the challenges of RYGB anatomy as a minimally invasive, clinically successful, fully endoscopic, and cost-effective option. We present a literature review of the EDGE technique from its inception to current, in addition to reviewing other access techniques, their advantages, disadvantages and outcomes.
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Affiliation(s)
- Harshit S Khara
- Department of Gastroenterology, Geisinger Medical Center, Danville, PA, 17822, USA.
| | - Swetha Parvataneni
- Department of Medicine, Geisinger Medical Center, Danville, PA, 17822, USA
| | - Steven Park
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Jihye Choi
- College of Art and Design, Rochester Institute of Technology, Rochester, NY, 14623, USA
| | - Truptesh H Kothari
- Department of Gastroenterology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Shivangi T Kothari
- Department of Gastroenterology, University of Rochester Medical Center, Rochester, NY, 14642, USA
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Honda H, Mosko JD, May GR. Management of combined malignant biliary-duodenal obstruction in Roux-en-Y gastric bypass anatomy with EUS-guided gastrogastrostomy, EUS biliary drainage, and duodenal stent placement. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2021; 6:260-262. [PMID: 34141967 PMCID: PMC8186001 DOI: 10.1016/j.vgie.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Video 1Demonstration of deploying lumen-apposing metal stents for gastrogastrostomy and choledochoduodenostomy in a patient with Roux-en-Y gastric bypass anatomy, as well as EUS-guided fine needle biopsy for pancreatic mass.
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Affiliation(s)
- Hirokazu Honda
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey D Mosko
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gary R May
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Jou J, Watson A, Zuchelli T. The use of a rescue stent in the management of lumen-apposing metal stent migration during EUS-directed transgastric ERCP with stent-in-stent technique to remove a forgotten metal biliary stent. VideoGIE 2021; 6:84-86. [PMID: 33884335 PMCID: PMC7859456 DOI: 10.1016/j.vgie.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jessica Jou
- Henry Ford Hospital, Division of Gastroenterology, Detroit, Michigan
| | - Andrew Watson
- Henry Ford Hospital, Division of Gastroenterology, Detroit, Michigan
| | - Tobias Zuchelli
- Henry Ford Hospital, Division of Gastroenterology, Detroit, Michigan
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Platt KD, Varban OA, Finks JF, Schulman AR. Thromboembolism and Fluid Collections Years Following Gastric Bypass: the Relevance of the Remnant. Obes Surg 2021; 31:2801-2805. [PMID: 33423182 DOI: 10.1007/s11695-020-05208-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin D Platt
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E. Medical Center Dr., 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA
| | - Oliver A Varban
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan F Finks
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E. Medical Center Dr., 3912 Taubman Center, Ann Arbor, MI, 48109-5362, USA.
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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Giménez M, Gallix B, Costamagna G, Vauthey JN, Moche M, Wakabayashi G, Bale R, Swanström L, Futterer J, Geller D, Verde JM, García Vazquez A, Boškoski I, Golse N, Müller-Stich B, Dallemagne B, Falkenberg M, Jonas S, Riediger C, Diana M, Kvarnström N, Odisio BC, Serra E, Overduin C, Palermo M, Mutter D, Perretta S, Pessaux P, Soler L, Hostettler A, Collins T, Cotin S, Kostrzewa M, Alzaga A, Smith M, Marescaux J. Definitions of Computer-Assisted Surgery and Intervention, Image-Guided Surgery and Intervention, Hybrid Operating Room, and Guidance Systems: Strasbourg International Consensus Study. ANNALS OF SURGERY OPEN 2020; 1:e021. [PMID: 33392607 PMCID: PMC7771637 DOI: 10.1097/as9.0000000000000021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/05/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To develop consensus definitions of image-guided surgery, computer-assisted surgery, hybrid operating room, and surgical navigation systems. SUMMARY BACKGROUND DATA The use of minimally invasive procedures has increased tremendously over the past 2 decades, but terminology related to image-guided minimally invasive procedures has not been standardized, which is a barrier to clear communication. METHODS Experts in image-guided techniques and specialized engineers were invited to engage in a systematic process to develop consensus definitions of the key terms listed above. The process was designed following review of common consensus-development methodologies and included participation in 4 online surveys and a post-surveys face-to-face panel meeting held in Strasbourg, France. RESULTS The experts settled on the terms computer-assisted surgery and intervention, image-guided surgery and intervention, hybrid operating room, and guidance systems and agreed-upon definitions of these terms, with rates of consensus of more than 80% for each term. The methodology used proved to be a compelling strategy to overcome the current difficulties related to data growth rates and technological convergence in this field. CONCLUSIONS Our multidisciplinary collaborative approach resulted in consensus definitions that may improve communication, knowledge transfer, collaboration, and research in the rapidly changing field of image-guided minimally invasive techniques.
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Affiliation(s)
- Mariano Giménez
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- DAICIM Foundation, Buenos Aires, Argentina
| | - Benôit Gallix
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Department of Radiology, McGill University & Health Centre, Quebec, Canada
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Moche
- Department of Interventional Radiology, Helios Park-Klinikum, Leipzig, Germany
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Reto Bale
- Interventional Oncology—Microinvasive Therapy (SIP), University Clinic for Radiology, Medical University, Innsbruck, Austria
| | - Lee Swanström
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
| | - Jürgen Futterer
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Geller
- Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Juan M. Verde
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- DAICIM Foundation, Buenos Aires, Argentina
| | - Alain García Vazquez
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- DAICIM Foundation, Buenos Aires, Argentina
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicolas Golse
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - Beat Müller-Stich
- Minimally Invasive Surgery, Surgical Clinic University Hospital, Heidelberg, Germany
| | - Bernard Dallemagne
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mårten Falkenberg
- Department of Radiology at the Department of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven Jonas
- Department of Visceral Surgery, 310Klinik, Nuremberg, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michele Diana
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Niklas Kvarnström
- Department of Surgery at Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bruno C. Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Didier Mutter
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Silvana Perretta
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Patrick Pessaux
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Alexandre Hostettler
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Toby Collins
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
| | | | - Michael Kostrzewa
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
| | | | - Martin Smith
- ‡‡‡Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacques Marescaux
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
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Hindryckx P, Degroote H. Lumen-apposing metal stents for approved and off-label indications: a single-centre experience. Surg Endosc 2020; 35:6013-6020. [PMID: 33051767 DOI: 10.1007/s00464-020-08090-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 10/03/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND STUDY AIMS Lumen-apposing stents (LAMS) are approved to treat peripancreatic collections and for gallbladder and bile duct drainage. Over the last years, LAMS have also been used for off-label indications including gastrojejunostomy, gastro-gastrostomy and drainage of postsurgical collections. We aimed to analyze indications, technical/clinical success rates and complications of all LAMS placed over the last 2 years. PATIENTS AND METHODS Data from 61 consecutive LAMS (Hot Axios, Boston Scientific) in 57 patients were analyzed. Technical success was defined as successful deployment of the LAMS in the desired position. Clinical success was defined as follows: for pancreatic collections: resolution without the need for non-endoscopic interventions; for choledochoduodenostomy: ≥ 50% drop in baseline serum bilirubin within 2 weeks AND patient can receive chemotherapy if indicated; for gastrojejunostomy: resolution of gastric outlet obstruction and successful re-initiation of oral intake; for gastro-gastrostomy: successful endoscopic access to the excluded stomach; for gallbladder or postsurgical collection drainage: resolution of sepsis. RESULTS Indications were drainage of peripancreatic collections in 24 cases (39.3%), choledochoduodenostomy in 13 (21.3%), gastrojejunostomy in 6 (9.8%), gastro-gastrostomy in 13 (21.3%), gallbladder drainage in 1 (1.6%) and postsurgical collection drainage in 4 (6.6%). Overall technical and clinical success rates were high (57/61; 93.4% and 54/61; 88.5%, respectively). Clinical success rate for non-approved indications was 95.6% (22/23 cases). Complications occurred in 13 patients (21.3%, 4 serious). CONCLUSIONS LAMS are increasingly used in interventional endoscopy. In our cohort, more than one third of LAMS are placed for off-label indications, with a high success rate and acceptable complication rate.
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Affiliation(s)
- Pieter Hindryckx
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Helena Degroote
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Wang TJ, Cortes P, Jirapinyo P, Thompson CC, Ryou M. A comparison of clinical outcomes and cost utility among laparoscopy, enteroscopy, and temporary gastric access-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Surg Endosc 2020; 35:4469-4477. [PMID: 32886240 DOI: 10.1007/s00464-020-07952-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Gastric Access Temporary for Endoscopy (GATE), also known as EUS-Directed Trangastric ERCP (EDGE), has demonstrated advantages over device-assisted enteroscopy (DAE) and laparoscopic-assisted ERCP (LA-ERCP) for patients with Roux-en-Y gastric bypass (RYGB) anatomy. We aimed to directly compare clinical outcomes and cost utility among the three ERCP modalities. METHODS Patients with RYGB anatomy who had DAE, LA-ERCP, or GATE from 2009 to 2019 at 2 tertiary centers were included in our review. We measured outcomes in three areas: success rate, post-procedural adverse events (AEs) and hospitalization, and cost utility per Medicare/Medicaid insurance payments. RESULTS Cohort Total 130 patients (70 underwent DAE, 42 LA-ERCP, and 18 GATE). Success rate DAE was successful in 59% of patients, compared to success rates of 98 and 100% for LA-ERCP and GATE, respectively (p < 0.001). For DAE, 62% of unsuccessful cases required rescue therapy. Adverse events and hospitalization Patients who underwent GATE had the lowest rate of hospitalization post procedure (44% vs. 77% and 100% for DAE and LA-ERCP, respectively, p < 0.01) and spent the least amount of time hospitalized (median time 0 days vs 2 and 3 days for DAE and LA-ERCP, respectively, p < 0.0001). GATE had lower AE rates than LA-ERCP (6 vs 31%, p = 0.046), and both had similar rates to DAE. Cost utility LA-ERCP carried the highest total procedural and hospitalization cost per Medicare/ Medicaid insurance payments (median payment difference of $9.7 K vs GATE and $7.9 K vs DAE, p < 0.01 for both). Procedural and hospitalization costs were similar between GATE and DAE (p = 0.76). CONCLUSIONS GATE is a safe modality for ERCP with high success rates in RYGB patients and exhibits the lowest hospitalization time and rate of adverse events when compared to DAE and LA-ERCP. GATE is similar to DAE from a cost utility approach, and both are less costly than LA-ERCP.
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Affiliation(s)
- Thomas J Wang
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Pedro Cortes
- Harvard Medical School, Boston, MA, USA.,Mayo Clinic, Jacksonville, FL, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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Koggel LM, Wahab PJ, Robijn RJ, Aufenacker TJ, Witteman BPL, Groenen MJM, Vrolijk JM. Efficacy and Safety of 100 Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography Procedures in Patients with Roux-en-Y Gastric Bypass. Obes Surg 2020; 31:987-993. [PMID: 32829445 PMCID: PMC7921030 DOI: 10.1007/s11695-020-04946-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/30/2022]
Abstract
Purpose Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) is an alternative for the anatomically challenging conventional ERCP in patients with a Roux-en-Y gastric bypass (RYGB) as it allows access to the biliary tree via the gastric remnant. We investigated the efficacy and safety of LAERCP. Material and Methods We retrospectively reviewed all charts from RYGB patients who underwent a LAERCP between January 2009 and August 2019 in a non-academic referral center for bariatric surgery. Patients who underwent pancreatic therapy were excluded. We collected demographic, clinical, and outcome data. An adverse event was defined as any complaint related to the LAERCP up to 30 days after the procedure and graded according to the ASGE lexicon. Results We identified 100 LAERCP in 86 patients with RYGB (70% female, median age 54 years). Same-session cholecystectomy was performed in 35 LAERCP (35%). The papilla of Vater was visualized in 100% of LAERCP with a therapeutic success rate of 94%. Stone extraction succeeded in 88.8% and sphincterotomy was performed in 96.7%. We identified 30 adverse events in 28 procedures, of which eight endoscopy-related, 14 laparoscopy-related, and eight non-specified (f.i. fever, allergic reaction). In total, six severe adverse events were reported concerning post-ERCP pancreatitis (n = 2), laparoscopy-related hemorrhage (n = 1), abscess (n = 1), shock (n = 1), and pneumonia (n = 1). No patient died due to LAERCP. Conclusion LAERCP is an effective and relatively safe procedure for biliary diseases in patients with RYGB.
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Affiliation(s)
- Lieke M Koggel
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Peter J Wahab
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Rob J Robijn
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | | | | | - Marcel J M Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - Jan M Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.
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Elsharif M, Hague AG, Ahmed H, Ackroyd R. After you Roux, what do you do? A systematic review of most successful advanced assisted ERCP techniques in patients with various altered upper gastrointestinal surgical anatomical reconstructions with particular focus on RYGB (last 10 years). Clin J Gastroenterol 2020; 13:985-1009. [PMID: 32809134 DOI: 10.1007/s12328-020-01201-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023]
Abstract
Access to the Common Bile Duct in patients with surgically altered UGI anatomy such as RYGB is exceptionally challenging. Previously, these patients could only be treated by open surgery; however, multiple new advanced assisted ERCP techniques such as EDGE, LA-ERCP, and DEA-ERCP have now been developed and indeed successfully used to treat these patients. Despite growing experience, these techniques have yet to become part of our mainstream practice and many clinicians remain unfamiliar or even unaware of them; as a result, they are unfortunately often overlooked. We conducted this systematic review to try and shed more light on them and understand which of these techniques resulted in the best patient outcomes. We conducted a systematic review of PubMed database publications between December 2008 and December 2018. Keyword variants of "EDGE, Enteroscopy-assisted & laparoscopy-assisted ERCP" and "altered surgical anatomy" were combined to identify relevant papers for inclusion. We identified 34 studies, comprising a total of 1848 advanced assisted ERCPs in patients with altered UGI anatomy from 12 different countries. These papers were critically appraised, summarised, and presented in table format. EDGE and LA-ERCP were associated with both the highest overall combined CBD cannulation rates (99.3% for both vs 74.6% for DEA-ERCP) and ERCP interventional success (98.3% for EDGE vs 97.4% for LA-ERCP and 67.6% for DEA-ERCP). Advanced ERCP is associated with excellent success rates and a higher safety profile than surgery; however, patient selection and identification of the exact surgical anatomy are key.
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Affiliation(s)
- Mohamed Elsharif
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK.
| | - Adam Gary Hague
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
| | - Hussam Ahmed
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
| | - Roger Ackroyd
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
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Kao LS, McCauley JS. Evidence-Based Management of Gallstone Pancreatitis. Adv Surg 2020; 54:173-189. [PMID: 32713429 DOI: 10.1016/j.yasu.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA.
| | - Jayne S McCauley
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA. https://twitter.com/JMcCauleyMD
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Sharma P, McCarty TR, Chhoda A, Costantino A, Loeser C, Muniraj T, Ryou M, Thompson CC. Alternative uses of lumen apposing metal stents. World J Gastroenterol 2020; 26:2715-2728. [PMID: 32550749 PMCID: PMC7284179 DOI: 10.3748/wjg.v26.i21.2715] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/27/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.
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Affiliation(s)
- Prabin Sharma
- Department of Gastroenterology and Hepatology, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06610, United States
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Ankit Chhoda
- Department of Internal Medicine, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06708, United States
| | - Antonio Costantino
- Department of Gastroenterology and Hepatology, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06610, United States
| | - Caroline Loeser
- Department of Gastroenterology and Hepatology, Yale-New Haven Health-Bridgeport Hospital, Bridgeport, CT 06610, United States
| | - Thiruvengadam Muniraj
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
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Dhindsa BS, Dhaliwal A, Mohan BP, Mashiana HS, Girotra M, Singh S, Ohning G, Bhat I, Adler DG. 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. [PMID: 32010749 PMCID: PMC6976316 DOI: 10.1055/a-1067-4411] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a new endoscopic procedure to perform ERCP in Roux-en-y gastric bypass (RYGB) patients. The aim of this study was to conduct a systematic review and meta-analysis to evaluate technical success, clinical success and adverse effects of EDGE and compare it to laparoscopic ERCP (LA-ERCP) and balloon ERCP (BE-ERCP). Patients and methods We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, LILACS, SCOPUS, and Web of Science databases to identify studies reporting on EDGE, LA-ERCP, and BE-ERCP. The primary outcome was to evaluate technical and clinical success of all three procedures and the secondary analysis focused on calculating the pooled rate of all adverse events (AEs), along with the commonly reported AE subtypes. Results Twenty-four studies on 1268 patients were included in our analysis with the majority of the population being males with mean age 53.72 years. Pooled rates of technical and clinical success with EDGE wer 95.5 % and 95.9 %, with LA-ERCP were 95.3 % and 92.9 % and were BE-ERCP were 71.4 % and 58.7 %, respectively. Pooled rates of all AEs with EDGE were 21.9 %, with LA-ERCP 17.4 % and with BE-ERCP 8.4 %. Stent migration was the most common AE with EDGE with 13.3 % followed by bleeding with 6.6 %. Conclusion Our meta-analysis demonstrated that the technical and clinical success of EDGE procedure is better than BE-ERCP and comparable to that of LA-ERCP in RYGB patients. EDGE also has a similar safety profile as compared to LA-ERCP but has higher AE rate as compared to BE-ERCP.
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Affiliation(s)
| | - Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Babu P. Mohan
- Banner University Medical Center, University of Arizona, Tucson, Arizona, United States
| | - Harmeet Singh Mashiana
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Mohit Girotra
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Gordon Ohning
- Division of Gastroenterology, University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, United States
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Douglas G. Adler
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah
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