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Endoscopy 2021; 53(06): 611-618
DOI: 10.1055/a-1254-3942
Original article

Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study

Thomas M. Runge
 1   Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Austin L. Chiang
 2   Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
,
Thomas E. Kowalski
 2   Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
,
Theodore W. James
 3   Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
,
Todd H. Baron
 3   Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
,
Jose Nieto
 4   Borland Groover Clinic, Advanced Therapeutic Endoscopy Center, Jacksonville, Florida, USA
,
David L. Diehl
 5   Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
,
Matthew R. Krafft
 6   Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
,
John Y. Nasr
 6   Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
,
Vikas Kumar
 5   Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
,
Harshit S. Khara
 5   Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
,
Shayan Irani
 7   Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
,
Arpan Patel
 8   Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
,
Ryan J. Law
 8   Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
,
David E. Loren
 2   Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
,
Alex Schlachterman
 2   Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
,
William Hsueh
 6   Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA
,
Bradley D. Confer
 5   Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA
,
Tyler K. Stevens
 9   Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
,
Prabhleen Chahal
 9   Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
,
Mohammad A. Al-Haddad
10   Division of Gastroenterology, Indiana School of Medicine, Indianapolis, Indiana, USA
,
Fahad Faisal Mir
11   Division of Gastroenterology, Department of Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
,
Douglas K. Pleskow
11   Division of Gastroenterology, Department of Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
,
Matthew T. Huggett
12   Department of Gastroenterology, St. James’ University Hospital, Leeds, UK
,
Bharat Paranandi
12   Department of Gastroenterology, St. James’ University Hospital, Leeds, UK
,
Arvind J. Trindade
13   Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York, USA
,
Olaya I. Brewer-Gutierrez
 1   Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Yervant Ichkhanian
 1   Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Mohamad Dbouk
 1   Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Vivek Kumbhari
 1   Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
,
Mouen A. Khashab
 1   Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Abstract

Background Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) is an alternative to enteroscopy- and laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Although short-term results are promising, the long-term outcomes are not known. The aims of this study were: (1) to determine the rates of long-term adverse events after EDGE, with a focus on rates of persistent gastrogastric or jejunogastric fistula; (2) to identify predictors of persistent fistula; (3) to assess the outcomes of endoscopic closure when persistent fistula is encountered.

Methods This was a multicenter retrospective study involving 13 centers between February 2015 and March 2019. Adverse events were defined according to the ASGE lexicon. Persistent fistula was defined as an upper gastrointestinal series or esophagogastroduodenoscopy showing evidence of fistula.

Results 178 patients (mean age 58 years, 79 % women) underwent EDGE. Technical success was achieved in 98 % of cases (175/178), with a mean procedure time of 92 minutes. Periprocedural adverse events occurred in 28 patients (15.7 %; mild 10.1 %, moderate 3.4 %, severe 2.2 %). The four severe adverse events were managed laparoscopically. Persistent fistula was diagnosed in 10 % of those sent for objective testing (9/90). Following identification of a fistula, 5 /9 patients underwent endoscopic closure procedures, which were successful in all cases.

Conclusions The EDGE procedure is associated with high clinical success rates and an acceptable risk profile. Persistent fistulas after lumen-apposing stent removal are uncommon, but objective testing is recommended to identify their presence. When persistent fistulas are identified, endoscopic treatment is warranted, and should be successful in closing the fistula.

Table 1s, 2s, Figs. 1s – 3s



Publication History

Received: 29 May 2020

Accepted: 03 September 2020

Accepted Manuscript online:
03 September 2020

Article published online:
23 November 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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