Clinical Endoscopy

Review

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography for patients with Roux-en-Y gastric bypass anatomy: technical overview: Hirokazu Honda, Jeffrey D. Mosko, Ryosuke Kobayashi, Andras Fecso, Bong Sik Kim, Schoeman Scott, Gary R. May; Clin Endosc 2022;55(6):736-741. Published online October 5, 2022; DOI: https://doi.org/10.5946/ce.2022.114

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass anatomy is a well-documented challenge. Traditionally, this problem has been overcome with adjunctive techniques, such as device-assisted ERCP, including double-balloon or single-balloon enteroscopy and laparoscopy-assisted transgastric ERCP. Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a novel technique that enables access to the ampulla using a duodenoscope without surgical intervention and has shown high clinical and technical success rates in recent studies. However, this approach is technically demanding, necessitating a thorough understanding of the gastrointestinal anatomy as well as high operator experience. In this review, we provide a technical overview of EDGE in parallel with our personal experience at our center and propose a simple algorithm to select patients for its appropriate application. In conjunction, the outcomes of EDGE compared with those of device-assisted and laparoscopy-assisted transgastric ERCP will be discussed.

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Reid D. Wasserman, Varun Kesar, Vivek Kesar, Paul Yeaton, Shehriyar Mehershahi
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Case Report

Management of Biliopancreatic Limb Bleeding after Roux-en-Y Gastric Bypass: A Case Report: Christophe Riquoir, Luis Antonio Díaz, David Chiliquinga, Roberto Candia, Fernando Pimentel, Alex Arenas; Clin Endosc 2021;54(5):754-758. Published online May 25, 2021; DOI: https://doi.org/10.5946/ce.2021.060

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The Roux-en-Y gastric bypass is one of the most extensive surgical treatments for obesity. The treatment of upper gastrointestinal bleeding after Roux-en-Y gastric bypass is complex due to the difficulty of accessing the excluded gastric antrum and duodenal bulb. There is no consensus regarding the management of this complication. While various techniques have been described to access the biliopancreatic limb, double-balloon enteroscopy is the most commonly used. If double-balloon enteroscopy is unavailable, a pediatric colonoscope may be used as an alternative; however, its use in such cases has not been described. We report the case of a 50-year-old male patient who underwent gastric bypass 13 years ago and was admitted for a second episode of upper gastrointestinal bleeding. The initial approach using upper endoscopy, colonoscopy, and abdominal computed tomography angiography did not reveal the cause of gastrointestinal hemorrhage; therefore, an endoscopic study of the biliopancreatic limb was performed using a pediatric colonoscope. A Forrest Ib ulcer was found in the duodenal bulb, and endoscopic therapy was administered. The evolution was found to be satisfactory.

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Endoscopic management of postoperative bleeding
Sung Hyeok Ryou, Ki Bae Bang
Clinical Endoscopy.2023; 56(6): 706. CrossRef

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Focused Review Series: Endoscopic Ultrasound-Guided Therapeutic Intervention: Focus on Technique and Practical Tips

Endoscopic Ultrasonography-Guided Gastroenterostomy Techniques for Treatment of Malignant Gastric Outlet Obstruction: Ryosuke Tonozuka, Takayoshi Tsuchiya, Shuntaro Mukai, Yuichi Nagakawa, Takao Itoi; Clin Endosc 2020;53(5):510-518. Published online September 23, 2020; DOI: https://doi.org/10.5946/ce.2020.151

Abstract PDF PubReader ePub

Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.

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Original Article

Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure: Amy Tyberg, Jose Nieto, Sanjay Salgado, Kristen Weaver, Prashant Kedia, Reem Z. Sharaiha, Monica Gaidhane, Michel Kahaleh; Clin Endosc 2017;50(2):185-190. Published online September 19, 2016; DOI: https://doi.org/10.5946/ce.2016.030

Abstract PDF PubReader ePub

Background
/Aims: Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone Rouxen-Y gastric bypass (RYGB) is challenging. Standard ERCP and enteroscopy-assisted ERCP are associated with limited success rates. Laparoscopy- or laparotomy-assisted ERCP yields improved efficacy rates, but with higher complication rates and costs. We present the first multicenter experience regarding the efficacy and safety of endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) or EUS.
Methods
All patients who underwent EDGE at two academic centers were included. Clinical success was defined as successful ERCP and/or EUS through the use of lumen-apposing metal stents (LAMS). Adverse events related to EDGE were separated from ERCP- or EUS-related complications and were defined as bleeding, stent migration, perforation, and infection.
Results
Sixteen patients were included in the study. Technical success was 100%. Clinical success was 90% (n=10); five patients were awaiting maturation of the fistula tract prior to ERCP or EUS, and one patient had an aborted ERCP due to perforation. One perforation occurred, which was managed endoscopically. Three patients experienced stent dislodgement; all stents were successfully repositioned or bridged with a second stent. Ten patients (62.5%) had their LAMS removed. The average weight change from LAMS insertion to removal was negative 2.85 kg.
Conclusions
EDGE is an effective, minimally invasive, single-team solution to the difficulties associated with ERCP in patients with RYGB.

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