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Endoscopy 2015; 47(02): 159-163
DOI: 10.1055/s-0034-1390771
Innovations and brief communications
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique

Prashant Kedia
1   Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
,
Nikhil A. Kumta
1   Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
,
Jessica Widmer
2   Division of Gastroenterology, North Shore-LIJ, Forest Hills Hospital, New York, USA
,
Subha Sundararajan
3   Red Bank Gastroenterology, Riverview Medical Center, New Jersey, USA
,
Mark Cerefice
4   Division of Gastroenterology, Jersey Shore University Medical Center, New Jersey, USA
,
Monica Gaidhane
1   Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
,
Reem Sharaiha
1   Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
,
Michel Kahaleh
1   Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
› Author Affiliations
Further Information

Publication History

submitted 03 April 2014

accepted after revision 28 August 2014

Publication Date:
09 January 2015 (online)

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Background: Patients with Roux-en-Y gastric bypass (RYGB) anatomy pose challenges when endoscopic retrograde cholangiopancreatography (ERCP) is required. Deep enteroscopy-assisted ERCP can allow pancreaticobiliary intervention in these patients, but with limited success. This case series describes endoscopic ultrasound-directed transgastric ERCP (EDGE) for patients following RYGB.

Methods: Patients with RYGB anatomy undergoing EDGE at a tertiary care center were included in this prospective single-arm feasibility study. All procedures were performed in two stages. First a 16-Fr percutaneous endoscopic gastrostomy (PEG) was placed in the excluded stomach using endoscopic ultrasound (EUS) guidance. Second, ERCP was performed through the newly fashioned gastrostomy and a transcutaneous fully covered metal esophageal stent.

Results: Six patients (5 women, 1 man) with RYGB anatomy underwent EDGE. EUS-guided PEG placement was successful in all six patients (100 %). Antegrade ERCP was successful in all six patients (100 %) with the stages being separated by a mean of 5.8 days. The mean procedure times for the two stages were 81 minutes and 98 minutes. Two patients (33 %) had localized PEG site infections that were managed with oral antibiotics. There were no adverse events related to ERCP.

Conclusions: EDGE is both feasible and safe to perform in RYGB patients. Given the high success rates of our recent experience, we suspect that this technique can be performed as a one-stage procedure to provide a cost-effective, minimally invasive option for a common problem in a growing patient population.

 

  • References

  • 1 Flegal KM, Carroll MD, Kit BK et al. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999 – 2010. JAMA 2012; 307: 491-497
    CrossrefPubMedGoogle Scholar
  • 2 Shiffman M, Sugerman H, Kellum J et al. Gallstones in patients with morbid obesity. Relationship to body weight, weight loss and gallbladder bile cholesterol solubility. Int J Obes Relat Metab Disord 1993; 13: 153-158
    PubMedGoogle Scholar
  • 3 Law R, Song LMWK, 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Shah RJ, Smolkin M, Yen R et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013; 77: 593-600
    CrossrefPubMedGoogle Scholar
  • 5 Schreiner M, Chang L, Gluck M et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 2012; 75: 748-756
    CrossrefPubMedGoogle Scholar
  • 6 Baron TH. Double-balloon enteroscopy to facilitate retrograde PEG placement as access for therapeutic ERCP in patients with long-limb gastric bypass. Gastrointest Endosc 2006; 64: 973-974
    CrossrefPubMedGoogle Scholar
  • 7 Ross AS, Semrad C, Alverdy J et al. Use of double-balloon enteroscopy to perform PEG in the excluded stomach after Roux-en-Y gastric bypass. Gastrointest Endosc 2006; 64: 797-800
    CrossrefPubMedGoogle Scholar
  • 8 Gutierrez JM, Lederer H, Krook JC et al. Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass. J Gastrointest Surg 2009; 13: 2170-2175
    CrossrefPubMedGoogle Scholar
  • 9 Nosher JL, Bodner LJ, Girgis WS et al. Percutaneous gastrostomy for treating dilatation of the bypassed stomach after bariatric surgery for morbid obesity. AJR Am J Roentgenol 2004; 183: 1431-1435
    CrossrefPubMedGoogle Scholar
  • 10 Stein EG, Cynamon J, Katzman MJ et al. Percutaneous gastrostomy of the excluded gastric segment after Roux-en-Y gastric bypass surgery. J Vasc Interv Radiol 2007; 18: 914-919
    CrossrefPubMedGoogle Scholar
  • 11 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
    CrossrefPubMedGoogle Scholar
  • 12 Wang AY, Sauer BG, Behm BW et al. Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy. Gastrointest Endosc 2010; 71: 641-649
    CrossrefPubMedGoogle Scholar