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Ahmed Z, Iqbal A, Aziz M, Iqbal F, Gangwani MK, Sohail A, Chaudhary A, Smith WL, Hayat U, Singh S, Mohan BP, Javaid T. Endoscopic ultrasound-guided antegrade treatment versus balloon enteroscopy endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis. Ann Gastroenterol 2024; 37:493-498. [PMID: 38974078 PMCID: PMC11226735 DOI: 10.20524/aog.2024.0888] [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: 02/26/2024] [Accepted: 04/22/2024] [Indexed: 07/09/2024] Open
Abstract
Background The safety and technical success of endoscopic ultrasound-guided antegrade treatment (EUS-AG) compared to balloon enteroscopy-assisted endoscopic cholangiopancreatography (BE-ERCP) for choledocholithiasis in Roux-en-Y gastrectomy has not been well documented. We performed a systematic review and meta-analysis to assess the safety and efficacy of the 2 procedures. Methods A systematic search of multiple databases was undertaken through January 25, 2024, to identify relevant studies comparing the 2 procedures. Standard meta-analysis methods were employed using a random-effects model. For each outcome, risk-ratio (RR), 95% confidence interval (CI), and P-values were generated. P<0.05 was considered significant. Heterogeneity was assessed using the I 2 statistic. Results Three studies with 795 patients (95 in the EUS-AG group and 700 in the BE-ERCP group) were included. The technical success rate was similar between EUS-AG and BE-ERCP (RR 1.08, 95%CI 0.84-1.38; P=0.57; I 2=56%). The overall rate of adverse effects was higher in the BE-ERCP group than in the EUS-AG group (RR 1.95, 95%CI 1.21-3.15; P=0.006; I 2=0 %). Rates of clinical success, pancreatitis, perforation, and bile peritonitis were similar between the 2 procedure techniques. Conclusions Our analysis showed no distinct advantage in using one technique over the other for patients with Roux-en-Y anatomy in achieving technical and clinical success. However, the incidence of adverse effects was greater in the BE-ERCP group than in the EUS-AG group.
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Affiliation(s)
- Zohaib Ahmed
- Department of Gastroenterology and Hepatology, University of Toledo, Ohio, USA (Zohaib Ahmed)
| | - Amna Iqbal
- Department of Internal Medicine, University of Toledo, Ohio, USA (Amna Iqbal, Manesh Kumar Gangwani)
| | - Muhammad Aziz
- Department of Gastroenterology, Bon secours Mercy Health, Toledo, Ohio, USA (Muhammad Aziz)
| | - Fatima Iqbal
- Department of Optometry, University of New South Wales, Sydney, Australia (Fatima Iqbal)
| | - Manesh Kumar Gangwani
- Department of Internal Medicine, University of Toledo, Ohio, USA (Amna Iqbal, Manesh Kumar Gangwani)
| | - Abdullah Sohail
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA (Abdullah Sohail)
| | - Ammad Chaudhary
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, USA (Ammad Chaudhary)
| | - Wade-Lee Smith
- University of Toledo Libraries, Ohio, USA (Wade-Lee Smith)
| | - Umar Hayat
- Department of Internal Medicine, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania, USA (Umar Hayat)
| | - Shailendra Singh
- Department of Gastroenterology and Hepatology, West Virginia University, Morgantown, West Virginia, USA (Shailendra Singh)
| | - Babu P. Mohan
- Department of Gastroenterology, Orlando Gastroenterology, Florida, USA (Babu P. Mohan)
| | - Toseef Javaid
- Department of Gastroenterology and Hepatology, United Health Services, Binghamton, New York, USA (Toseef Javaid)
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Pérez-Cuadrado-Robles E, Alric H, Quénéhervé L, Monino L, Poghosyan T, Benosman H, Vienne A, Perrod G, Rebibo L, Aidibi A, Tenorio-González E, Ragot E, Karoui M, Cellier C, Rahmi G. Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using a standardized protocol (with video). Dig Endosc 2023; 35:909-917. [PMID: 36872440 DOI: 10.1111/den.14544] [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: 11/19/2022] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP. METHODS Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed. RESULTS Forty-five ERCPs were performed in 31 patients (57.4 ± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n = 28, 90.3%) for biliary stones (n = 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n = 24, 77.4%) and mainly in the middle-excluded stomach (n = 21, 67.7%) with an oblique axis (n = 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n = 8), anastomotic dilation (n = 8), or failure to pass (n = 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P = 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P = 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P = 0.465). CONCLUSIONS The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.
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Affiliation(s)
- Enrique Pérez-Cuadrado-Robles
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Cité University, Paris, France
| | - Hadrien Alric
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Cité University, Paris, France
| | - Lucille Quénéhervé
- Department of Gastroenterology, University Hospital of Brest, Brest, France
| | - Laurent Monino
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Tigran Poghosyan
- Paris Cité University, Paris, France
- Department of Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Hedi Benosman
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ariane Vienne
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Perrod
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Rebibo
- Department of Surgery, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Cité University, Paris, France
| | - Ali Aidibi
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Elena Tenorio-González
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emilia Ragot
- Department of Surgery, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mehdi Karoui
- Department of Surgery, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Cité University, Paris, France
| | - Christophe Cellier
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Cité University, Paris, France
| | - Gabriel Rahmi
- >Department of Gastroenterology, Georges-Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Cité University, Paris, France
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Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis. Surg Endosc 2023:10.1007/s00464-023-09926-7. [PMID: 36792784 DOI: 10.1007/s00464-023-09926-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/28/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND In patients with Roux-en-Y gastric bypass (RYGB) anatomy, laparoscopic endoscopic retrograde cholangiopancreatography (LA-ERCP) and enteroscopy-assisted ERCP (E-ERCP) have been utilized to achieve pancreaticobiliary access. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has recently emerged as an alternate and efficient approach. As data regarding EDGE continues to evolve, concerns about safety and efficacy remain, limiting wide adoptability. We performed a systematic review and meta-analysis to assess the safety and efficacy of EDGE and compare it to the current standard of care. METHODS A comprehensive search of major databases (inception to Nov 2022) identified published studies on EDGE. A random-effects model was used to calculate the pooled rates and heterogeneity (I2). Risk ratio (RR) and standardized difference in means (SMD) were utilized for head-to-head comparison analysis between EDGE vs. LA-ERCP and EDGE vs. E-ERCP. Primary outcomes assessed pooled EDGE safety (adverse events) and efficacy (technical/clinical success). Secondary outcomes assessed efficacy and safety profiles via a comparative analysis of EDGE vs. LA-ERCP and EDGE vs. E-ERCP. RESULTS A total of 16 studies (470 patients) were included. EDGE pooled technical success (TS) rate was 96% (95% CI 92-97.6, I2 = 0), and clinical success was 91% (85-95, I2 = 0). Pooled rate of all adverse events with EDGE was 17% (14-24.6, I2 = 32%). On sub-group analysis, these included failure of fistula closure 17% (10-25.5, I2 = 48%), stent migration 7% (4-12, I2 = 51%), bleeding 5% (3.2-7.9, I2 = 0), post-EDGE weight gain 4% (2-9, I2 = 0), perforation 4% (2.1-5.8, I2 = 0), and post-ERCP pancreatitis 2% (1-5, I2 = 0). EDGE TS was comparable to LA-ERCP (97% vs. 98%; RR, 1.00; CI, 0.85-1.17, p = 0.95) and E-ERCP (100% vs. 66%; RR, 1.26; CI, 0.99-1.6, p = 0.06). No statistical difference was noted in adverse events between EDGE and LA-ERCP (13% vs. 17.6%; RR, 0.61; CI, 0.28-1.35, p = 0.52) and E-ERCP (9.6% vs. 16%; RR, 0.61; CI, 0.28-1.35, p = 0.22). EDGE procedure time and hospital stay were shorter than LA-ERCP and E-ERCP (p < 0.001). CONCLUSION Our analysis shows that EDGE is safe and efficacious to the current standard of care. Further head-to-head comparative trials are needed to validate our findings.
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Altieri MS, Rogers A, Afaneh C, Moustarah F, Grover BT, Khorgami Z, Eisenberg D. Bariatric Emergencies for the General Surgeon. Surg Obes Relat Dis 2023; 19:421-433. [PMID: 37024348 DOI: 10.1016/j.soard.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 02/04/2023] [Indexed: 02/16/2023]
Affiliation(s)
- Maria S Altieri
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Ann Rogers
- Department of Surgery, Hershey School of Medicine, Penn State University, Hershey, Pennsylvania
| | | | - Fady Moustarah
- Department of Surgery, Beaumont Hospital, Bloomfield Hills, Michigan
| | - Brandon T Grover
- Department of Surgery, Gundersen Lutheran Medical Center, La Crosse, Wisconsin
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma College of Community Medicine, Tulsa, Oklahoma; Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Dan Eisenberg
- Department of Surgery, Stanford School of Medicine and VA Palo Alto Health Care System, Palo Alto, California
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Belgau I, Johnsen G, Græslie H, Mårvik R, Nymo S, Bjerkan K, Hyldmo Å, Klöckner C, Kulseng B, Hoff D, Sandvik J. Frequency of cholelithiasis in need of surgical or endoscopic treatment a decade or more after Roux-en-Y gastric bypass. Surg Endosc 2023; 37:1349-1356. [PMID: 36203112 PMCID: PMC9944031 DOI: 10.1007/s00464-022-09676-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Symptomatic cholelithiasis requiring treatment is a known side effect after Roux-en-Y gastric bypass (RYGB), but reported rates vary greatly. The objectives for this study were to evaluate the long-term frequency of surgical or endoscopic treatment for symptomatic cholelithiasis 10-15 years after RYGB and its relation to self-reported abdominal pain. METHODS Observational data from 546 patients who underwent RYGB at public hospitals in Central Norway between March 2003 and December 2009 were analyzed. RESULTS Median follow-up was 11.5 (range 9.1-16.8) years. Sixty-five (11.9%) patients had undergone cholecystectomy prior to RYGB. Out of the 481 patients with intact gallbladder, 77 (16.0%) patients underwent cholecystectomy and six (1.2%) patients had treatment for choledocholithiasis during the observation period. Median time from RYGB to cholecystectomy or treatment of choledocholithiasis was 51 (range 1-160) and 109 (range 10-151) months, respectively. Female sex was associated with an increased risk of subsequent cholecystectomy [OR (95% CI) 2.88 (1.31-7.15)], p < 0.05. There was a higher frequency of self-reported abdominal pain at follow-up [OR (95% CI) 1.92 (1.25-2.93)] among patients who underwent cholecystectomy before or after RYGB. CONCLUSION With a median follow-up of more than 11 years after RYGB, one in six patients with an intact gallbladder at time of RYGB underwent cholecystectomy, and 1.1% of the patients needed surgical or endoscopic treatment for choledocholithiasis. Patients with a history of cholecystectomy reported a higher frequency of abdominal pain.
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Affiliation(s)
- Ingrid Belgau
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway
| | - Gjermund Johnsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway ,Norwegian National Advisory Unit on Advanced Laparoscopic Surgery, Clinic of Surgery, St. Olav’s University Hospital, Trondheim, Norway
| | - Hallvard Græslie
- Clinic of Surgery, Nord-Trøndelag Hospital Trust, Namsos Hospital, Namsos, Norway
| | - Ronald Mårvik
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway ,Norwegian National Advisory Unit on Advanced Laparoscopic Surgery, Clinic of Surgery, St. Olav’s University Hospital, Trondheim, Norway
| | - Siren Nymo
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway ,Clinic of Surgery, Nord-Trøndelag Hospital Trust, Namsos Hospital, Namsos, Norway
| | - Kirsti Bjerkan
- Faculty of Social Science and History, Volda University College, Volda, Norway ,Department of Surgery, Møre and Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway
| | - Åsne Hyldmo
- Centre for Obesity Research, Clinic of Surgery, St. Olav’s University Hospital, Prinsesse Kristina’s Gate 3, 7030 Trondheim, Norway
| | - Christian Klöckner
- Centre for Obesity Research, Clinic of Surgery, St. Olav’s University Hospital, Prinsesse Kristina’s Gate 3, 7030 Trondheim, Norway
| | - Bård Kulseng
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway
| | - Dag Hoff
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway ,Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Jorunn Sandvik
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway. .,Department of Surgery, Møre and Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway. .,Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Prinsesse Kristina's Gate 3, 7030, Trondheim, Norway.
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Chhabra P, On W, Paranandi B, Huggett MT, Robson N, Wright M, Maher B, Tehami N. Initial United Kingdom experience of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography. Ann Hepatobiliary Pancreat Surg 2022; 26:318-324. [PMID: 36042580 PMCID: PMC9721259 DOI: 10.14701/ahbps.22-019] [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] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 12/15/2022] Open
Abstract
Backgrounds/Aims Gallstone disease is a recognized complication of bariatric surgery. Subsequent management of choledocholithiasis may be challenging due to altered anatomy which may include Roux-en-Y gastric bypass (RYGB). We conducted a retrospective service evaluation study to assess the safety and efficacy of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in patients with RYGB anatomy. Methods All the patients who underwent EDGE for endoscopic retrograde cholangiopancreatography after RYGB at two tertiary care centers in the United Kingdom between January 2020 and October 2021 were included in the study. Clinical and demographic details were recorded for all patients. The primary outcome measures were technical and clinical success. Adverse events were recorded. Hot Axios lumen apposing metal stents measuring 20 mm in diameter and 10 mm in length were used in all the patients for creation of a gastro-gastric or gastro-jejunal fistula. Results A total of 14 patients underwent EDGE during the study period. The majority of the patients were female (85.7%) and the mean age of patients was 65.8 ± 9.8 years. Technical success was achieved in all but one patient at the first attempt (92.8%) and clinical success was achieved in 100% of the patients. Complications arose in 3 patients with 1 patient experiencing persistent fistula and weight gain. Conclusions In patients with RYGB anatomy, EDGE facilitated biliary access has a high rate of clinical success with an acceptable safety profile. Adverse events are uncommon and can be managed endoscopically.
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Affiliation(s)
- Puneet Chhabra
- Department of Gastroenterology, Calderdale and Huddersfield Foundation Trust, Huddersfield, United Kingdom
| | - Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Matthew T. Huggett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Naomi Robson
- Biomedical Communications, University of Toronto, Toronto, Ontario, Canada
| | - Mark Wright
- Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Ben Maher
- Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Nadeem Tehami
- Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom,Corresponding author: Nadeem Tehami, BSc, FRCP (London), FRCPS (Glasg), FEBGH, MRCP Gastroenterology Department of Interventional Endoscopy, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom Tel: +44-23-8077-7222, E-mail: ORCID: https://orcid.org/0000-0003-3042-6574
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Gkolfakis P, Papaefthymiou A, Facciorusso A, Tziatzios G, Ramai D, Dritsas S, Florou T, Papanikolaou IS, Hassan C, Repici A, Triantafyllou K, Aabakken L, Devière J, Beyna T, Arvanitakis M. Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12101646. [PMID: 36295081 PMCID: PMC9605390 DOI: 10.3390/life12101646] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP. Methods: A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs). Results: Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3–89.4); I2: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4–99.4; I2: 0%) and 99.1% (95%CI: 98.6–99.7; I2: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3–78.0; I2: 86.9%) and 69.1% (95%CI: 65.3–72.9; I2: 91.8%) after EA-ERCP, 98% (95%CI: 96.5–99.6; I2: 0%) and 97.9% (95%CI: 96.3–99.4) after EDGE, and 98.6% (95%CI: 97.9–99.2; I2: 0%) and 98.5% (95%CI: 97.8–99.2; I2: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40–20.8); I2: 87.1%], and EDGE [13.1% (95%CI: 7.50–18.8); I2: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50–6.80); p ≤ 0.04; I2: 64.2%]. Conclusions: LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
| | | | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, 124 62 Chaidari, Greece
- Correspondence: ; Tel.: +30-6942259009
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Spyridon Dritsas
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil BA21 4AT, UK
| | - Theodosia Florou
- Department of Gastroenterology, University Hospital of Larissa, 411 10 Larissa, Greece
| | - Ioannis S. Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, 124 62 Chaidari, Greece
| | - Cesare Hassan
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Alessandro Repici
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, 124 62 Chaidari, Greece
| | - Lars Aabakken
- GI Endoscopy Unit, Institute of Clinical Medicine, Oslo University Hospital, 0372 Oslo, Norway
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
| | - Torsten Beyna
- Department of Internal Medicine, Evagelisches Krankenhaus Düsseldorf, 40225 Düsseldorf, Germany
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
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de Oliveira VL, de Moura DTH, do Monte Júnior ES, Proença IM, Ribeiro IB, Sánchez-Luna SA, Ribas PHBV, Hemerly MC, Bernardo WM, de Moura EGH. Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography (ERCP) Versus Endoscopic Ultrasound-Directed Transgastric ERCP in Patients With Roux-en-Y Gastric Bypass: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e30196. [PMID: 36381817 PMCID: PMC9649332 DOI: 10.7759/cureus.30196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for skilled endoscopists that can be even more challenging in some situations, including patients' post-Roux-en-y Gastric Bypass (RYGB) surgery. There is still no consensus on whether laparoscopic-assisted ERCP (LA-ERCP) or endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) is the most appropriate, safe, and feasible approach in patients with this type of post-surgical anatomy. This systematic review and meta-analysis aimed to examine both approaches' feasibility, efficacy, and safety in this situation. We searched for electronic databases (MEDLINE, EMBASE, Lilacs, Google Scholar, and Central Cochrane) to identify studies comparing LA-ERCP versus EDGE. Outcomes measured included technical success, adverse events (AEs) and serious AEs, length of stay (LOS), and procedural time. Descriptive data related to the EDGE procedure was also extracted. The risk of bias and the quality of evidence of the enrolled studies were assessed. Five studies, totalizing 268 patients (176 LA-ERCP and 92 EDGE), were included. There was no statistical difference in technical success and AEs between groups; however, the LOS and procedural times were shorter for the EDGE group. High rates of fistula closure and no weight regain were observed in EDGE. Both methods are feasible and safe techniques to perform ERCP in patients with RYGB anatomy, with comparable technical success and adverse events rate. However, EDGE is associated with shorter LOS and procedural time.
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Affiliation(s)
- Victor L de Oliveira
- Gastroenterology, Hospital das Clínicas da Universidade de São Paulo, Sao Paulo, BRA
| | | | | | - Igor M Proença
- Gastroenterology, Hospital das Clínicas da Universidade de São Paulo, Sao Paulo, BRA
| | - Igor B Ribeiro
- Gastroenterology, Hospital das Clínicas da Universidade de São Paulo, Sao Paulo, BRA
| | - Sergio A Sánchez-Luna
- Gastroenterology, University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Birmingham, USA
| | | | - Matheus C Hemerly
- Gastroenterology, Hospital das Clínicas da Universidade de São Paulo, Sao Paulo, BRA
| | - Wanderley M Bernardo
- Gastroenterology, Hospital das Clínicas da Universidade de São Paulo, Sao Paulo, BRA
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Campbell J, Pryor A, Docimo S. Transcystic Choledochoscopy Utilizing a Disposable Choledochoscope: How We Do It. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2022; 32:616-620. [PMID: 35960694 DOI: 10.1097/sle.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Biliary disease is common occurrence and can make up a large portion of the practice of a general surgeon. Choledocholithasis is a common entity amongst those with biliary disease. Although modern trends favor endoscopic retrograde cholangiopancreatography (ERCP) and other imaging modalities for the diagnosis and management of choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is likely underutilized. METHODS A literature summary utilizing a PUBMED search was performed to provide an up-to-date account regarding the latest data on LCBDE. A video identifying and explaining the critical components of a LBCDE procedure is provided. RESULTS LCBDE is an underutilized procedure which offers equivalent clinical outcomes compared with ERCP along with a shorter length of stay and reduced costs. LCBDE is also noted to be an effective option for common bile duct stones in the setting of altered anatomy, such as a Roux-en-Y gastric bypass. CONCLUSION Although modern trends favor ERCP and other imaging modalities for the diagnosis and management of choledocholithiasis, LCBDE is likely underutilized by surgeons. LCBDE can provide many benefits to patients including avoidance of additional procedures, shorter length of stay, higher success rates, and less costs. Out video should act is a guide for those surgeons interested in implementation LCBDE in their practice.
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Affiliation(s)
- John Campbell
- General Surgery Resident, Stony Brook Medicine, Stony Brook, NY
| | - Aurora Pryor
- Surgery, Chief Bariatric, Foregut and Advanced GI Surgery, Vice Chair for Clinical Affairs, Stony Brook University
| | - Salvatore Docimo
- Surgery, University of South Florida, Morsani College of Medicine, Tampa, FL
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10
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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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Podboy A, Gaddam S, Park K, Gupta K, Liu Q, Lo SK. Management of Difficult Choledocholithiasis. Dig Dis Sci 2022; 67:1613-1623. [PMID: 35348969 DOI: 10.1007/s10620-022-07424-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 12/13/2022]
Abstract
Over 30% of all endoscopic retrograde cholangiography procedures in the US are associated with biliary stone extraction, and over 10-15% of these cases are noted to be complex or difficult. The aim of this review is to define the characteristics of difficult common bile duct stones and provide an algorithmic therapeutic approach to these difficult cases. We describe additional special clinical circumstances in which difficult biliary stones are identified and provide additional management strategies to aid endoscopic stone extraction efforts.
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Affiliation(s)
- Alexander Podboy
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Srinivas Gaddam
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Kenneth Park
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Kapil Gupta
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Quin Liu
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA
| | - Simon K Lo
- Pancreatic and Biliary Disease Program, Department of Digestive Diseases, Cedars Sinai Medical Center, 8700 Beverly Boulevard, South Tower, Suite 7511, Los Angeles, CA, 90048, USA.
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Das JK, Rangad GM. Hepaticojejunostomy Anastomosis Worm Obstruction and Its Laparoscopic Management: A Case Report and Review of Literature. Cureus 2022; 14:e21968. [PMID: 35282540 PMCID: PMC8905378 DOI: 10.7759/cureus.21968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
We report a surprising case of intraoperatively detected worm obstruction of a hepaticojejunostomy anastomosis. The patient presented with acute cholangitis including fever, abdominal pain, obstructive jaundice and sepsis. Six years earlier, she had undergone open cholecystectomy with a right subcostal incision. Ultrasonography that night depicted the absence of the gall bladder and the presence of apparent stones in the common hepatic and common bile ducts. The patient was posted for laparoscopic exploration of common bile duct. Intraoperatively, worm obstruction was found in the hepaticojejunostomy anastomosis created during the previous operation. The obstruction was managed laparoscopically, and the patient recovered without any complications and was monitored for two years. In a search of PubMed and Google Scholar, we found reports of laparoscopy-assisted endoscopic retrograde cholangiopancreatography as an established method of relieving hepaticojejunostomy obstruction; however, we found no case of laparoscopic extraction of obstructing worms. Laparoscopic exploration of a hepaticojejunostomy anastomosis through the afferent Roux loop is a feasible and safe alternative to other advanced methods of endoscopic retrograde cholangiopancreatography, for which special technique, logistics, and training are required but may not be available in many parts of the world.
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Affiliation(s)
- Jayanta Kumar Das
- Department of General and Minimally Invasive Surgery, Nazareth Hospital, Shillong, IND
| | - Gordon M Rangad
- Department of General and Minimally Invasive Surgery, Nazareth Hospital, Shillong, IND
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Larsen M, Kozarek R. Therapeutic endoscopy for the treatment of post-bariatric surgery complications. World J Gastroenterol 2022; 28:199-215. [PMID: 35110945 PMCID: PMC8776527 DOI: 10.3748/wjg.v28.i2.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/15/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.
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Affiliation(s)
- Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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Sanders DJ, Bomman S, Krishnamoorthi R, Kozarek RA. Endoscopic retrograde cholangiopancreatography: Current practice and future research. World J Gastrointest Endosc 2021; 13:260-274. [PMID: 34512875 PMCID: PMC8394185 DOI: 10.4253/wjge.v13.i8.260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.
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Affiliation(s)
- David J Sanders
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Shivanand Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, United States
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Kumbhari V, le Roux CW, Cohen RV. Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review. Obes Surg 2021; 31:4624-4633. [PMID: 34331187 DOI: 10.1007/s11695-021-05603-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.
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Affiliation(s)
- Vivek Kumbhari
- Department of Gastroenterology and Hepatology, The Johns Hopkins University, 1800 Orleans St, Suite 7125B, Baltimore, MD, USA. .,Department of Gastroenterology and Hepatology, Mayo Clinic, 1800 Orleans St, Suite 7125B, Florida, FL, USA.
| | - Carel W le Roux
- Diabetes Complications Research Centre, University College Dublin, Dublin, Ireland
| | - Ricardo V Cohen
- The Center for the Treatment of Obesity and Diabetes, Hospital Oswaldo Cruz, Sao Paulo, Brazil
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Clinical Impact of Antecedent Bariatric Surgery on Liver Transplant Outcomes: A Retrospective Matched Case-control Study. Transplantation 2021; 105:1280-1284. [PMID: 32590608 DOI: 10.1097/tp.0000000000003378] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bariatric surgery (BS) may be associated with significant malabsorption and nutritional deficiencies. METHODS Between March 1987 and January 2017, we performed 922 liver transplants (LT) at our institution; 33 had antecedent BS. We matched the BS cohort to LT recipients without BS (1:3 matching) based on exact matching for gender and cancer and inverse variance matching for age, LT body mass index, MELD score, and transplant date. RESULTS We analyzed outcomes in 132 LT recipients (33 BS; 99 non-BS). The BS cohort comprised 26 (79%) women with a mean age of 52.4 years. The BS procedures included 20 Roux-en-Y gastric bypass (61%), 6 jejunoileal bypass (18%), 3 gastric band (9%), 2 sleeve gastrectomy (6%), and 1 duodenal switch (3%). The primary indications for LT listing were alcoholic cirrhosis (9; 27%), nonalcoholic steatohepatitis (7; 21%), hepatitis C (8; 24%), and hepatocellular carcinoma (3; 9%). At LT, body mass index for the BS cohort was 29.6, and MELD was 24. Compared with matched controls, BS recipients did not have longer LT length of hospital stay (17.8 versus 15.7 d, P = 0.71), longer intensive care unit length of stay (5.3 versus 4.1 d, P = 0.16), or higher 30-day complication rate (76% versus 85%, P = 0.43). Overall patient survival was similar (1- and 3-y survival was 90.1% and 75.9% for BS; 90.9% and 76.4% for non-BS, P = 0.34). CONCLUSIONS A history of BS does not portend a deleterious effect on LT outcomes.
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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Mazzeo C, Badessi G, Pallio S, Viscosi F, Cucinotta E. Laparoscopic assisted ERCP in patient with Roux-en-Y gastric bypass. A case report. Int J Surg Case Rep 2021; 81:105837. [PMID: 33887848 PMCID: PMC8050726 DOI: 10.1016/j.ijscr.2021.105837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Choledocholithiasis in Roux-en-Y patients is a therapeutic challenge for both surgeons and endoscopists. In fact, typical procedures, such as ERCP, can't be performed due to the altered anatomy of the patient. Nowadays, procedures on this kind of patient are performed not only in specialized bariatric centers, but, due to the increasing number of patients undergoing bariatric surgery, are starting to become more common even in smaller and non-specialized centers that don't possess the same expertise and technology. CASE PRESENTATION We present the case of a 33-year-old patient, who had already undergone bariatric surgery, and presented to our department with a diagnosis of choledocholithiasis. Due to the altered anatomy the patient was treated through a laparoscopic assisted ERCP. DISCUSSION A review of the need and proper timing for a cholecystectomy in this kind of patient, in order to prevent choledocholithiasis, is discussed. Moreover, a review of the literature regarding the possible treatments of this pathology in bariatric patients underlines the presence of other treatments, beyond the one performed in our department, that can be performed even in small non-specialized centers. CONCLUSIONS Prophylactic cholecystectomy is not recommended in bariatric surgery. Laparoscopic assisted-ERCP is a safe and feasible intervention which is to be preferred, even if B-ERCP and EDGE are two valid alternatives.
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Affiliation(s)
- Carmelo Mazzeo
- Department of General and Emergency Surgery, Policlinico G. Martino, University of Messina, Italy
| | - Giorgio Badessi
- Department of General and Emergency Surgery, Policlinico G. Martino, University of Messina, Italy.
| | - Socrate Pallio
- Digestive Endoscopy Unit, Policlinico G. Martino, University of Messina, Italy
| | - Francesca Viscosi
- Department of General and Emergency Surgery, Policlinico G. Martino, University of Messina, Italy
| | - Eugenio Cucinotta
- Department of General and Emergency Surgery, Policlinico G. Martino, University of Messina, Italy
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Martin H, El Menabawey T, Webster O, Parisinos C, Chapman M, Pereira SP, Johnson G, Webster G. Endoscopic biliary therapy in the era of bariatric surgery. Frontline Gastroenterol 2021; 13:133-139. [PMID: 35295751 PMCID: PMC8862446 DOI: 10.1136/flgastro-2020-101755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/04/2021] [Accepted: 02/07/2021] [Indexed: 02/04/2023] Open
Abstract
There is an increasing demand and availability of bariatric surgery, with a range of procedures performed, some leading to altered upper gastrointestinal anatomy. The patient population undergoing bariatric surgery is also at increased risk of gallstones and biliary stone disease. Endoscopy (ie, endoscopic retrograde cholangiopancreatography) is the cornerstone of management of biliary stone disease, but may be challenging after bariatric surgery. In this review the endoscopic, surgery assisted, or percutaneous options that may be considered are discussed, based on the details of surgical anatomy and available expertise.
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Affiliation(s)
- Harry Martin
- Pancreaticobiliary Medicine, University College London Hospitals, London, UK
| | - Tareq El Menabawey
- Pancreaticobiliary Medicine, University College London Hospitals, London, UK
| | - Orla Webster
- University of Bristol Medical School, Bristol, Bristol, UK
| | | | - Michael Chapman
- Pancreaticobiliary Medicine, University College London Hospitals, London, UK
| | - Stephen P Pereira
- Pancreaticobiliary Medicine, University College London Hospitals, London, UK,University College London Medical School, The UCL Institute of Hepatology, London, UK
| | - Gavin Johnson
- Pancreaticobiliary Medicine, University College London Hospitals, London, UK
| | - George Webster
- Pancreaticobiliary Medicine, University College London Hospitals, London, UK
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Fuente I, Beskow A, Wright F, Uad P, de Santibañes M, Palavecino M, Sanchez-Claria R, Pekolj J, Mazza O. Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass. Surg Endosc 2021; 35:6913-6920. [PMID: 33398581 DOI: 10.1007/s00464-020-08201-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/19/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB. METHODS This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE. RESULTS Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004). CONCLUSIONS LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.
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Affiliation(s)
- Ignacio Fuente
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina.
| | - Axel Beskow
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Fernando Wright
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Pedro Uad
- Bariatric Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martín de Santibañes
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martin Palavecino
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Rodrigo Sanchez-Claria
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Juan Pekolj
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Oscar Mazza
- HPB Section, General Surgery Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABD, Buenos Aires, Argentina
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Espinel Díez J, Pinedo Ramos ME. Single-balloon enteroscopy-assisted ERCP in patients with Roux-en-Y anatomy and choledocholithiasis: do technical improvements mean better outcomes? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:929-934. [PMID: 33226253 DOI: 10.17235/reed.2020.7287/2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy is challenging. Single-balloon enteroscopy-assisted ERCP (SBE-ERCP) is an innovative alternative to reach the bile duct. OBJECTIVE to report our experience in SBE-ERCP in patients who presented with Roux-en-Y anatomy and choledocholithiasis. PATIENTS AND METHODS patients who presented choledocholithiasis and underwent SBE-ERCP between January 2018 and April 2020 were retrospectively identified via medical records and the digestive endoscopy database. Enteroscopy success was defined as reaching the biliary limb and papilla identification. ERCP diagnostic success was defined as a successful duct cannulation and cholangiography, and ERCP procedural success was defined as the ability to successfully carry out choledocholithiasis extraction. Complications of ERCP were defined according to standard criteria. RESULTS a total of eleven patients (two females) with a mean age of 81 years (range 60-91 years) with Roux-en-Y anastomosis underwent ERCP using a SBE on 13 occasions. The indication for all procedures was choledocholithiasis, which had been previously confirmed by magnetic resonance cholangiopancreatography (MRCP). Enteroscopy success occurred in 13/13 (100 %) of procedures. Overall ERCP diagnostic success was achieved in 11/13 (84.6 %) of procedures. The ERCP procedural success was obtained in 11/11 (100 %) of patients (84.6 % of procedures). A mild pancreatitis occurred in a patient with native papilla. CONCLUSIONS SBE-ERCP is feasible, efficacious and safe in patients with postsurgical Roux-en-Y anatomy and choledocholithiasis. Technical improvements may mean better outcomes.
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Neuhaus H, Beyna T. Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery. VideoGIE 2020; 6:27-29. [PMID: 33490751 PMCID: PMC7806500 DOI: 10.1016/j.vgie.2020.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Horst Neuhaus
- Department of Internal Medicine, Gastroenterology and Interventional Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Torsten Beyna
- Department of Internal Medicine, Gastroenterology and Interventional Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
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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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