Endoscopic ultrasound-directed transgastric ERCP (EDGE): A multicenter US study on long-term follow-up and fistula closure

Background and study aims  Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a safe and efficacious procedure to treat pancreaticobiliary diseases in Roux-en-Y gastric bypass (RYGB). This multicenter study aimed to determine the long-term outcomes of EDGE focusing on fistula persistence rates and post-procedure weight change. Patients and methods  Information about patients with Roux-en-Y gastric bypass anatomy who underwent EDGE between 2015 and 2021 from 10 institutions was captured in a registry. Patient demographics, procedural details, and clinical outcomes were analyzed. Results  One hundred seventy-two patients were included in the study (mean age 60, 25 % male). Technical success of lumen-apposing metal stent (LAMS) placement was 171 of 172 (99.4 %) while clinical success of intervention was 95%. The mean procedure time was 65 minutes. The most commonly reported complication was stent dislodgement/migration (n = 29, 17). Mean length of time of LAMS duration was 69 days. Mean follow-up time was 6 months. Endoscopic fistula closure was performed in 40 % of patients (69/172) at the time of LAMS removal. Persistence of fistula was observed in 19 of 62 patients (31 %) assessed. Length of LAMS indwell time (days) was a predictor of persistent fistula. The average weight gain while the LAMS was in place was 12 lb in 63 patients (36.6 %); 59.4 % of patients gained < 5 lb. Conclusions  EDGE is a safe and efficacious procedure for RYGB patients requiring ERCP. Post-procedure evaluation and management of the enteral fistula varies widely among centers currently and would benefit from further standardization. Fistula persistence appears to be uncommon and can be managed endoscopically but may be related to length of indwell times of the LAMS.

Invasive CO 2 monitoring with arterial line compared to end tidal CO 2 during peroral endoscopic myotomy

Background and study aims  Peroral endoscopic myotomy (POEM) has become a recognized treatment for achalasia. The technique requires CO 2 insufflation. It is estimated that the partial pressure of CO 2 (PaCO 2 ) is 2 to 5 mm Hg higher than the end tidal CO 2 (etCO 2 ), and etCO 2 is used as a surrogate for PaCO 2 because PaCO 2 requires an arterial line. However, no study has compared invasive and noninvasive CO 2 monitoring during POEM. Patients and methods  Seventy-one patients who underwent POEM were included in a prospective comparative study. PaCO 2 plus etCO 2 was measured in 32 patients (invasive group) and etCO 2 only in 39 matched patients (noninvasive group). Pearson correlation coefficient (PCC) and Spearman's Rho were used to calculate the correlation between PaCO 2 and ETCO 2 . Results  PaCO 2 and ETCO 2 were strongly correlated: PCC R value: 0.8787 P  ≤ 0.00001, Spearman's Rho R value: 0.8775, P  ≤ 0.00001. Within the invasive group, the average difference between PaCO 2 and ETCO 2 was 3.39 mm Hg (median 3, standard deviation 3.5), within the 2- to 5-mm Hg range. The average procedure time (scope in to scope out) was increased 17.7 minutes ( P  = 0.044) and anesthesia duration was 46.3 minutes. Adverse events (AEs) included three hematomas and one nerve injury in the invasive group and one pneumothorax in the noninvasive group. There were no differences in AE rates between the groups (13 % vs 3 % P  = 0.24). Conclusions  Universal PaCO 2 monitoring contributes to increased procedure and anesthesia times without any decrease in AEs in patients undergoing POEM. CO 2 monitoring with an arterial line should only be performed in patients with major cardiovascular comorbidities; in all other patients, ETCO 2 is an appropriate tool.