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Elfert K, Kahaleh M. Approaches to Pancreaticobiliary Endoscopy in Roux-en-Y Gastric Bypass Anatomy. Gastrointest Endosc Clin N Am 2024; 34:475-486. [PMID: 38796293 DOI: 10.1016/j.giec.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
The increasing prevalence of bariatric surgery, particularly Roux-en-Y gastric bypass, has necessitated innovative approaches for endoscopic retrograde cholangiopancreatography (ERCP) due to the altered anatomy. Laparoscopy-assisted ERCP offers high success rates but leads to extended hospital stays and an increased risk of adverse events. Enteroscopy-assisted ERCP encounters technical challenges, resulting in lower success rates. A novel technique, endoscopic ultrasound-directed transgastric ERCP, employs a lumen-apposing metal stent to create a fistula connecting the gastric pouch to the excluded stomach, enabling ERCP and other endoscopic procedures. Common adverse events include perforation, stent migration, bleeding, and fistula persistence.
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Affiliation(s)
- Khaled Elfert
- SBH Health System, CUNY School of Medicine, 4422 3rd Avenue, Bronx, NY 10457, USA
| | - Michel Kahaleh
- Department of Gastroenterology, Robert Wood Johnson University Hospital, RWJ Place, MEB 464, New Brunswick, NJ 08901, USA.
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Gangwani MK, Aziz M, Haghbin H, Iqbal A, Dillard J, Dahiya DS, Ali H, Hayat U, Khuder S, Lee-Smith W, Nawras Y, Kamal F, Inamdar S, Alastal Y, Thosani N, Adler D. Comparing EUS-directed Transgastric ERCP (EDGE) Versus Laparoscopic-Assisted ERCP Versus Enteroscopic ERCP: A Network Meta-analysis. J Clin Gastroenterol 2024; 58:110-119. [PMID: 38019046 DOI: 10.1097/mcg.0000000000001949] [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] [Indexed: 11/30/2023]
Abstract
BACKGROUND Management of choledocholithiasis in patients with Roux-en-Y gastric bypass surgery is challenging. This study aims to compare technical success rates, adverse events, and procedural time between 3 current approaches: endoscopic ultrasound-directed transgastric Endoscopic retrograde cholangiopancreatography (ERCP) (EDGE), enteroscopy-assisted ERCP (E-ERCP), and laparoscopic-assisted ERCP (LA-ERCP). METHODS A systematic search of 5 databases was conducted. Direct and network meta-analyses were performed to compare interventions using the random effects model. A significance threshold of P < 0.05 was applied. RESULTS Sixteen studies were included. On direct meta-analysis, technical success rates were comparable between EDGE and LA-ERCP (odds ratio: 0.768, CI: 0.196-3.006, P = 0.704, I2 = 14.13%). However, EDGE and LA-ERCP showed significantly higher success rates than E-ERCP. No significant differences in adverse events were found between EDGE versus LA-ERCP, EDGE versus E-ERCP, and LA-ERCP versus E-ERCP on direct meta-analysis. In terms of procedural time, EDGE was significantly shorter than E-ERCP [mean difference (MD): -31 minutes, 95% CI: -40.748 to -21.217, P < 0.001, I2 = 19.89%), and E-ERCP was shorter than LA-ERCP (MD: -44.567 minutes, 95% CI: -76.018 to -13.116, P = 0.005, I2 = 0%). EDGE also demonstrated a significant time advantage over LA-ERCP (MD: -78.145 minutes, 95% CI: -104.882 to -51.407, P < 0.001, I2 = 0%). All findings were consistent with network meta-analysis on random effects model. The heterogeneity of the model was low. CONCLUSIONS EDGE and LA-ERCP showed superior technical success rates compared with E-ERCP. Adverse events did not significantly differ among the three approaches. Furthermore, EDGE demonstrated the shortest procedural duration. We recommend considering EDGE as a first-choice procedure.
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Affiliation(s)
| | - Muhammad Aziz
- Gastroenterology and Hepatology, University of Toledo Medical Center
| | - Hossein Haghbin
- Department of Gastroenterology and Hepatology, Ascension Providence Hospital, Southfield
| | | | | | - Dushyant S Dahiya
- Department of Medicine, Central Michigan University College of Medicine, Mount Pleasant, MI
| | - Hassam Ali
- Department of Gastroenterology and Hepatology, East Carolina University Health, Greenville, NC
| | - Umar Hayat
- Department of Medicine, Geisinger Wyoming Valley Medical Center, Wilkes-Barre
| | - Sadik Khuder
- Department of Medicine and School of Population Health
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH
| | | | - Faisal Kamal
- Digestive Health Institute, Thomas Jefferson University, Philadelphia, PA
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Yaseen Alastal
- Gastroenterology and Hepatology, University of Toledo Medical Center
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School at UTHealth, Houston, TX
| | - Douglas Adler
- Center for Advanced Therapeutic Endoscopy, Porter Adventist Hospital, Centura Health, Denver, CO
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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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Saad B, Nasser M, Matar RH, Nakanishi H, Tosovic D, Than CA, Taha-Mehlitz S, Taha A. Safety and efficacy of LA-ERCP procedure following Roux-en-Y gastric bypass: a systematic review and meta-analysis. Surg Endosc 2023; 37:6682-6694. [PMID: 37479839 PMCID: PMC10462525 DOI: 10.1007/s00464-023-10276-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/02/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Rapid weight loss following Roux-en-Y gastric bypass surgery (RYGB) translates to an increased need for endoscopic retrograde cholangiopancreatography (ERCP) intervention. Laparoscopically Assisted Transgastric ERCP (LA-ERCP) has emerged to address the issue of accessing the excluded stomach. This study aims to evaluate the safety and efficacy of LA-ERCP procedure following RYGB. METHODS The Cochrane, EMBASE, SCOPUS, MEDLINE, Daily and Epub databases were searched from inception to May 2022 using the PRISMA guidelines. Eligible studies reported participants older than 18 years who underwent the LA-ERCP procedure, following RYGB, and outcomes of patients. RESULTS 27 unique studies met the inclusion criteria with 1283 patients undergoing 1303 LA-ERCP procedures. 81.9% of the patients were female and the mean age was 52.18 ± 13.38 years. The rate of concurrent cholecystectomy was 33.6%. 90.9% of procedures were undertaken for a biliary indication. The mean time between RYGB and LA-ERCP was 89.19 months. The most common intervention performed during the LA-ERCP was a sphincterotomy (94.3%). Mean total operative time was 130.48 min. Mean hospital length of stay was 2.697 days. Technical success was 95.3%, while clinical success was 93.8%. 294 complications were recorded with a 20.6% complication rate. The most frequent complications encountered were pancreatitis (6.8%), infection (6.1%), bleeding (3.4%), and perforation (2.5%). Rate of conversion to open laparotomy was 7%. CONCLUSION This meta-analysis presents preliminary evidence to suggest the safety and efficacy of LA-ERCP procedure following RYGB. Further investigations are warranted to evaluate the long-term efficacy of this procedure using studies with long-term patient follow-up.
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Affiliation(s)
- Baraa Saad
- St George's University of London, London, SW17 0RE, UK
| | - Maya Nasser
- St George's University of London, London, SW17 0RE, UK
| | - Reem H Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA
| | | | - Danijel Tosovic
- School of Biomedical Sciences, The University of Queensland, St Lucia, Brisbane, 4072, Australia
| | - Christian A Than
- School of Biomedical Sciences, The University of Queensland, St Lucia, Brisbane, 4072, Australia
| | - Stephanie Taha-Mehlitz
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4002, Basel, Switzerland
| | - Anas Taha
- Department of Biomedical Engineering, Faculty of Medicine, University of Basel, 4123, Allschwil, Switzerland.
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Papaefthymiou A, Ramai D, Maida M, Tziatzios G, Viesca MFY, Papanikolaou I, Paraskeva K, Triantafyllou K, Repici A, Hassan C, Binda C, Beyna T, Facciorusso A, Arvanitakis M, Gkolfakis P. Performance and safety of motorized spiral enteroscopy: a systematic review and meta-analysis. Gastrointest Endosc 2023; 97:849-858.e5. [PMID: 36738795 DOI: 10.1016/j.gie.2023.01.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/11/2022] [Accepted: 01/28/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The introduction of motorized spiral enteroscopy (mSE) into clinical practice holds diagnostic and therapeutic potential for small-bowel investigations. This systematic review and meta-analysis aims to evaluate the performance of this modality in diagnosing and treating small-bowel lesions. METHODS A systematic search of MEDLINE, Cochrane, and ClinicalTrials.gov databases were performed through September 2022. The primary outcome was diagnostic success, defined as the identification of a lesion relative to the indication. Secondary outcomes were successful therapeutic manipulation, total enteroscopy rate (examination from the duodenojejunal flexion to the cecum), technical success (passage from the ligament of Treitz or ileocecal valve for anterograde and retrograde approach, respectively), and adverse event rates. We performed meta-analyses using a random-effects model, and the results are reported as percentages with 95% confidence intervals (CIs). RESULTS From 2016 to 2022, 9 studies (959 patients; 42% women; mean age >45 years; 474 patients [49.4%] investigated for mid-GI bleeding/anemia) were considered eligible and included in analysis. The diagnostic success rate of mSE was 78% (95% CI, 72-84; I2 = 78.3%). Considering secondary outcomes, total enteroscopy was attempted in 460 cases and completed with a rate of 51% (95% CI, 30-72; I2 = 96.2%), whereas therapeutic interventions were successful in 98% of cases (95% CI, 96-100; I2 = 79.8%) where attempted. Technical success rates were 96% (95% CI, 94-97; I2 = 1.5%) for anterograde and 97% (95% CI, 94-100; I2 = 38.6%) for retrograde approaches, respectively. Finally, the incidence of adverse events was 17% (95% CI, 13-21; I2 = 65.1%), albeit most were minor adverse events (16%; 95% CI, 11-20; I2 = 67.2%) versus major adverse events (1%; 95% CI, 0-1; I2 = 0%). CONCLUSIONS mSE provides high rates of diagnostic and therapeutic success with a low prevalence of severe adverse events.
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Affiliation(s)
- Apostolis Papaefthymiou
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London, UK; First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Macedonia, Greece
| | - Daryl Ramai
- Department of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah, USA
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta, Italy
| | - Georgios Tziatzios
- Department of Gastroenterology, General Hospital of Nea Ionia "Konstantopoulio-Patision," Athens, Greece
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, ULB, Brussels, Belgium
| | - Ioannis Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantina Paraskeva
- Department of Gastroenterology, General Hospital of Nea Ionia "Konstantopoulio-Patision," Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Alessandro Repici
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Cesare Hassan
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Italy
| | - Torsten Beyna
- Department of Internal Medicine, Evagelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, ULB, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, General Hospital of Nea Ionia "Konstantopoulio-Patision," Athens, Greece; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, ULB, Brussels, Belgium
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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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Ghandour B, Keane MG, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Sharaiha RZ, Kowalski TE, Khashab MA, Shrigiriwar A, Zhang L, Mony S, Khan A, Loren DE, Chiang A, Schlachterman A, Kumar A, Saab O, Blake B, Obri MS. Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study. Gastrointest Endosc 2023; 97:260-267. [PMID: 36228699 DOI: 10.1016/j.gie.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. METHODS This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). CONCLUSIONS Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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8
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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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9
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Ghandour B, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Bejjani M, Sharaiha RZ, Kowalski TE, Khashab MA. EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience. Gastrointest Endosc 2022; 96:630-638. [PMID: 35623383 DOI: 10.1016/j.gie.2022.05.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. METHODS This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. RESULTS Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. CONCLUSIONS EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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10
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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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11
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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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12
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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: 153] [Impact Index Per Article: 76.5] [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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13
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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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14
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Kilic Y, Graham A, Tait NP, Spalding D, Vlavianos P, Jiao LR, Alsafi A. Percutaneous biliary stone clearance: is there still a need? A 10-year single-centre experience. Clin Radiol 2021; 77:130-135. [PMID: 34893340 DOI: 10.1016/j.crad.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/21/2021] [Indexed: 11/18/2022]
Abstract
AIM To evaluate the safety and efficacy of percutaneous biliary stone clearance in a single hepatopancreaticobiliary (HPB) centre. MATERIALS AND METHODS All patients who underwent percutaneous biliary stone clearance between 2010 and 2020 at a HPB centre were identified from the radiology information system. Their demographic data, presentation, previous surgery, number/size of biliary calculi, success and complications were collected from patient records. Unpaired student's t-test was used to compare numerical variables and the Chi-square test was used to compare categorical data. RESULTS Sixty-eight patients aged between 58.5-91.1 years underwent the procedure, and 42.6% (29/68) had the procedure due to surgically altered anatomy precluding endoscopic retrograde cholangiopancreatography (ERCP). The most common presentation was cholangitis (62%). The success rate of percutaneous stone clearance was 92.7%. The average number of calculi was two (range 1-412). Of the patients included, 4.4% developed pancreatitis, 4.4% developed cholangitis, and 1.5% had hepatic artery branch pseudoaneurysm successfully treated with transarterial embolisation. There was no significant difference in success or complication rates between the different access sites (right lobe, left lobe, roux-loop, T-tube, p=0.7767). CONCLUSION Percutaneous biliary stone clearance is safe and effective and will continue to play an important role where ERCP fails or is impossible due surgically altered anatomy.
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Affiliation(s)
- Y Kilic
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - A Graham
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - N P Tait
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - D Spalding
- Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
| | - P Vlavianos
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - L R Jiao
- Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
| | - A Alsafi
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
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15
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Bronswijk M, Vanella G, Persyn D, Van der Merwe S. EUS-directed transgastric ERCP: Why so on EDGE? Gastrointest Endosc 2021; 94:1152-1153. [PMID: 34798927 DOI: 10.1016/j.gie.2021.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Diederik Persyn
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Department of Gastroenterology and Hepatology, AZ Damiaan, Oostende, Belgium
| | - Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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16
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Abstract
PURPOSE OF REVIEW To update on recent advances in interventional endoscopic ultrasound (INVEUS) techniques. RECENT FINDINGS The introduction of linear echoendoscopes with larger instrument channels and the combined development of new tools and devices have enabled various new applications of minimally invasive endoscopic ultrasound (EUS)-guided transluminal interventions of the pancreas, biliary system and peri-gastrointestinal structures. In this review, EUS-guided interventions are discussed and evaluated: drainage of peripancreatic fluid collections, access and drainage of bile ducts, gallbladder and pancreatic duct, treatment of gastrointestinal haemorrhage, coeliac plexus block and coeliac plexus neurolysis, fiducial placement, solid and cystic tumour ablation, drug delivery and brachytherapy, gastroenterostomy, angiotherapy and other EUS-guided applications. The EUS-guided interventions are classified based on the available evidence as established or experimental, standardized or nonstandardized procedures in common or rare diseases with well or little known complications and their established or nonestablished treatment. SUMMARY Some EUS-guided interventions have sparse published evidence with only single-centre studies, case series or individual case reports, others like drainage of peripancreatic fluid collections have become widely accepted practice. INVEUS has been accepted as an alternative to several surgical approaches, EUS-guided techniques result in faster recovery times, shorter hospital stay and lower costs.
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Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Switzerland
| | - Barbara Braden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany
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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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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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