ENDOSCOPIC ULTRASOUND-DIRECTED TRANSGASTRIC ERCP (EDGE) IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS (RYGB): TECHNIQUE AND RESULTS IN A EUROPEAN CASES SERIES

Aims To describe technique, efficacy and safety of EDGE in RYGB.

Methods 14 consecutive patients [12 female; 56(±9.7)years] identified from prospective database underwent EDGE at tertiary Unit (6 choledocholithiasis; 3 cholangitis; 2 pancreatitis; 3 other). Definitions: Complete therapeutic cycle (CTC) = EUS-Directed Gastro-gastrostostomy/gastro-jejunostomy (EUS-GG/GJ) + transgastric ERCP + transmural stent removal; Index procedure = creation of EUS-GG; Single session procedure (SSP) = EUS-GG and ERCP under the same sedation. Technique, procedural issues and clinical outcomes were reviewed.

Results 14 EDGE anastomoses were 9 GG and 5 GJ. Bridging stents: 4 duodenal 20-mm PC-SEMS, 10 cautery-enabled 20-mm LAMS, without suture-anchoring. SSP was tried in 12: 9 successful (75%), 2 dislodgements (managed endoscopically) and 1 ERCP aborted by friction. Eventually, papillary access was obtained in 16/19 ERCPs (13 patients): 9 successful SSPs; 4 dual-session procedures [mean (range) = 22 (4-34) days]; 3 for follow-up procedures (hemostasis/biliary stent revision), with technical success in 15/16 (94%). There were 2 other late intraprocedural stent dislodgements (1 in patient with prior SSP dislodgment/one resolved by transfistulous ERCP). Complications: 2 pain, 1 post-sphincterotomy bleeding (21% patients; 15% sessions; all mild). Transgastric stents were removed without complications after a median (IQR) of 30(7-65) days in 12 CTC patients, all resolved. Closure techniques were used in 50% (4 pigtails/2 OTSC), typically for dislodgement and/or early closure. A median (IQR) of 256(104-787) days post-removal of transgastric stents, the 12 CTC patients remain without recurrence or fistula. There are 2 patients with fistula kept with LAMS/pig-tail (one each) pending re-ERCP (1 access failed due to dislodgement during SSP; another successful access with incomplete ERCP).

Conclusions 20-mm metal stents (FC-SEMS or LAMS) allow single-session EDGE in most patients with RYGB. Suture-anchoring appears unnecessary. The mall risk of dislodgement appears to be related to angulation. Dislodgement can usually be managed endoscopically.