The EDGI new take on EDGE: EUS-directed transgastric intervention (EDGI), other than ERCP, for Roux-en-Y gastric bypass anatomy: a multicenter study
submitted 25. März 2019
accepted after revision 25. April 2019
01. Oktober 2019 (online)
Background and study aims Indications for accessing the duodenum, and/or excluded stomach in Roux-en-Y gastric bypass (RYGB) patients extend beyond diagnosis and treatment of pancreaticobiliary maladies. Given the high technical and clinical success of EUS-directed transgastric ERCP (EDGE) in RYGB anatomy, we adopted this transgastric (anterograde) approach to evaluate and treat luminal and extraluminal pathology in and around the excluded gut in RYGB patients. EUS-directed transgastric intervention (“EDGI”), other than ERCP, is the terminology we have chosen to describe this heterogenous group of transgastric diagnostic and/or interventional endoscopic procedures (transgastric interventions) performed via a lumen-apposing mental stent (LAMS) in select patients with RYGB.
Patients and methods A multicenter (n = 4), retrospective study of RYGB patients with suspected luminal or extraluminal pathology, in or around the duodenum and/or excluded stomach, underwent EDGI using LAMS between December 2015 and January 2019.
Results A total of 14 patients (78.6 % women; mean age, 55.7 + 12.4 years) underwent EDGI via LAMS. Technical and clinical success rates of EDGI were 100 %. The most common transgastric interventions were diagnostic EUS of extraluminal pathology (n = 6, 42.7 %) and endoscopic biopsy of gastroduodenal luminal abnormalities (n = 5, 35.7 %). Two moderate-severity adverse events due to LAMS maldeployment occurred during EUS-JG creation (14.3 %), and each instance was successfully rescued with a bridging stent.
Conclusions A variety of gastroduodenal luminal and extraluminal disorders in RYGB patients can be effectively diagnosed and managed using EDGI via LAMS.
- 1 Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013; 23: 427-436
- 2 Tran DD, Nwokeabia ID, Purnell S. Revision of Roux-En-Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg 2016; 26: 1627-1634
- 3 Baron TH, Vickers SM. Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Gastrointest Endosc 1998; 48: 640-641
- 4 Law R, Wong Kee Song LM, Petersen BT. et al. Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy 2013; 45: 671-675
- 5 Attam R, Leslie D, Freeman M. et al. EUS-assisted, fluoroscopically guided gastrostomy tube placement in patients with Roux-en-Y gastric bypass: a novel technique for access to the gastric remnant. Gastrointest Endosc 2011; 74: 677-682
- 6 Kedia P, Kumta NA, Clavo CMR. et al. Endoscopic ultrasound-directed transgastric ERCP (Edge) for Roux-en-Y anatomy. Gastrointest Endosc 2014; 79: AB411
- 7 Kedia P, Sharaiha RZ, Kumta NA. et al. Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology 2014; 147: 566-568
- 8 Kedia P, Tyberg A, Kumta NA. et al. EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc 2015; 82: 560-565
- 9 James TW, Baron TH. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a single-center US experience with follow-up data on fistula closure. Obes Surg 2019; 29: 451-456
- 10 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
- 11 American Society of Metabolic and Bariatric Surgery (ASMBS). Estimate of bariatric surgery numbers. Available at: http://asmbs.org/resources/estimate-of-bariatric-surgery-numbers ; Accessed December 17, 2018
- 12 Kuga R, Safatle-Ribeiro AV, Faintuch J. Endoscopic findings in the excluded stomach after Roux-en-Y gastric bypass surgery. Arch Surg 2007; 142: 942-946
- 13 Mahawar KK, Kumar P, Parmar C. Small bowel limb lengths and Roux-en-Y gastric bypass: a review. Obes Surg 2016; 26: 660-671
- 14 Siddique SS, Feuerstein JD. Gastrointestinal complications of Roux-en-Y gastric bypass surgery. OA Minim Invas Surg 2014; 2: 1
- 15 Shiffman ML, Sugerman HJ, Kellum JM. et al. Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am J Gastroenterol 1991; 86: 1000-1005
- 16 Bukhari M, Kowalski T, Nieto J. et al. An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc 2018; 88: 486-494
- 17 Tyberg A, Nieto J, Salgado D. et al. Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc 2017; 50: 185-190
- 18 Kedia P, Tarnasky PR, Nieto J. et al. EUS-directed transgastric ERCP (EDGE) versus laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y gastric bypass (RYGB) anatomy: a multicenter early comparative experience of clinical outcomes. J Clin Gastroenterol 2019; 53: 304-308