Ann Hepatobiliary Pancreat Surg.  2022 Nov;26(4):318-324. 10.14701/ahbps.22-019.

Initial United Kingdom experience of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography

• Chhabra P
• On W
• Paranandi B
• Huggett MT
• Robson N
• Wright M
• Maher B
• Tehami N

• KMID: 2536381
• DOI: http://doi.org/10.14701/ahbps.22-019

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.

Keyword

Endosonography; Cholangiopancreatography; endoscopic retrograde; Choledocholithiasis; Gastric bypass; Gallstones

Figure

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  Fig. 1 A pictorial representation of EDGE. EDGE, endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography.

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  Fig. 2 Endoscopic ultrasound image showing the excluded stomach.

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  Fig. 3 Endoscopic ultrasound (EUS) image showing EUS-guided 19G needle puncture into the cavity of the excluded stomach.

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  Fig. 4 Fluoroscopy image showing Injection of contrast into the excluded stomach.

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  Fig. 5 Endoscopic ultrasound image showing deployment of the distal flange of lumen apposing metal stent into the residual stomach.

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  Fig. 6 Occlusion cholangiogram showing dilated common bile duct with no obvious filling defect.

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