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Gellért B, Rancz A, Hoferica J, Teutsch B, Sipos Z, Veres DS, Hegyi PJ, Ábrahám S, Hegyi P, Hritz I. Understanding the Role of Different ERCP Techniques in Post-Roux-en-Y Gastric Bypass Patients: a Systematic Review and Meta-analysis. Obes Surg 2025; 35:285-304. [PMID: 39671059 PMCID: PMC11717856 DOI: 10.1007/s11695-024-07459-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 12/14/2024]
Abstract
We aimed to compare enteroscopy-assisted ERCP (EA-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and endoscopic ultrasound-directed ERCP (EDGE) in terms of safety and efficacy in post-Roux-en-Y gastric bypass patients. We conducted a rigorous analysis based on a predefined protocol (PROSPERO, CRD42022368788). Sixty-seven studies were included. The technical success rates were 77% (CI 69-83%) for EA-ERCP, 93% (CI 91-96%) for LA-ERCP, and 96% (CI 92-98%) for EDGE. Subgroup differences were significant between the EA-ERCP and other groups (p < 0.05). The overall adverse event rates were 13% (CI 8-22%), 19% (CI 14-24%), and 20% (CI 12-31%), respectively (p = 0.49). Our findings suggest that EDGE and LA-ERCP may be more effective and as safe as EA-ERCP.
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Affiliation(s)
- Bálint Gellért
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
- Department of Surgery, Transplantation and Gastroenterology, Division of Interventional Gastroenterology, Semmelweis University, Üllői Út 78, 1082, Budapest, Hungary
| | - Anett Rancz
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
- Department of Internal Medicine and Hematology, Medical School, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
| | - Jakub Hoferica
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
- Jessenius Faculty of Medicine in Martin, Comenius University, Malá Hora 4A, 036 01, Martin-Záturčie, Slovakia
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti Út 12, 7624, Pécs, Hungary
- Department of Radiology, Medical Imaging Centre, Semmelweis University, Korányi Sándor U. 2, 1082, Budapest, Hungary
| | - Zoltán Sipos
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti Út 12, 7624, Pécs, Hungary
- Institute of Bioanalysis, Medical School, University of Pécs, Honvéd Utca 1, 7624, Pécs, Hungary
| | - Dániel S Veres
- Department of Biophysics and Radiation Biology, Semmelweis University, Tűzoltó U. 37-47, 1094, Budapest, IX, Hungary
| | - Péter Jenő Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Tömő Utca 25-29, 1083, Budapest, Hungary
| | - Szabolcs Ábrahám
- Department of Surgery, Albert Szent-Györgyi Medical School, University of Szeged, H-6725 Tisza Utca 109, Szeged, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1085, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti Út 12, 7624, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Tömő Utca 25-29, 1083, Budapest, Hungary
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, H-6725 Tisza Utca 109, Szeged, Hungary
| | - István Hritz
- Department of Surgery, Transplantation and Gastroenterology, Division of Interventional Gastroenterology, Semmelweis University, Üllői Út 78, 1082, Budapest, Hungary.
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Papasavas P, Docimo S, Oviedo RJ, Eisenberg D. Biliopancreatic access following anatomy-altering bariatric surgery: a literature review. Surg Obes Relat Dis 2022; 18:21-34. [PMID: 34688572 DOI: 10.1016/j.soard.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/19/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Pavlos Papasavas
- Division of Metabolic and Bariatric Surgery, Hartford Hospital, Hartford, Connecticut.
| | - Salvatore Docimo
- Division of Bariatric, Foregut, and Advanced GI Surgery, Stony Brook Medicine, Stony Brook, New York
| | | | - Dan Eisenberg
- Department of Surgery, Stanford University and Palo Alto VA Health Care Center, Palo Alto, California
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Shinn B, Boortalary T, Raijman I, Nieto J, Khara HS, Kumar SV, Confer B, Diehl DL, El Halabi M, Ichkhanian Y, Runge T, Kumbhari V, Khashab M, Tyberg A, Shahid H, Sarkar A, Gaidhane M, Bareket R, Kahaleh M, Piraka C, Zuchelli T, Law R, Sondhi A, Kedia P, Robbins J, Calogero C, Bakhit M, Chiang A, Schlachterman A, Kowalski T, Loren D. Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration. Gastrointest Endosc 2021; 94:727-732. [PMID: 33957105 DOI: 10.1016/j.gie.2021.04.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. METHODS We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. RESULTS Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. CONCLUSIONS Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.
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Affiliation(s)
- Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tina Boortalary
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida, USA
| | | | - S Vikas Kumar
- Geisinger Health System, Danville, Pennsylvania, USA
| | | | - David L Diehl
- Geisinger Health System, Danville, Pennsylvania, USA
| | - Maan El Halabi
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | | | - Thomas Runge
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Mouen Khashab
- Johns Hopkins University Hospital, Baltimore, Maryland, USA
| | - Amy Tyberg
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Monica Gaidhane
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Romy Bareket
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Michel Kahaleh
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Cyrus Piraka
- Henry Ford Health System, Detroit, Michigan, USA
| | | | - Ryan Law
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Arjun Sondhi
- University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | - Justin Robbins
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cristina Calogero
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mena Bakhit
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Austin Chiang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Thomas Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Loren
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Elsharif M, Hague AG, Ahmed H, Ackroyd R. After you Roux, what do you do? A systematic review of most successful advanced assisted ERCP techniques in patients with various altered upper gastrointestinal surgical anatomical reconstructions with particular focus on RYGB (last 10 years). Clin J Gastroenterol 2020; 13:985-1009. [PMID: 32809134 DOI: 10.1007/s12328-020-01201-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023]
Abstract
Access to the Common Bile Duct in patients with surgically altered UGI anatomy such as RYGB is exceptionally challenging. Previously, these patients could only be treated by open surgery; however, multiple new advanced assisted ERCP techniques such as EDGE, LA-ERCP, and DEA-ERCP have now been developed and indeed successfully used to treat these patients. Despite growing experience, these techniques have yet to become part of our mainstream practice and many clinicians remain unfamiliar or even unaware of them; as a result, they are unfortunately often overlooked. We conducted this systematic review to try and shed more light on them and understand which of these techniques resulted in the best patient outcomes. We conducted a systematic review of PubMed database publications between December 2008 and December 2018. Keyword variants of "EDGE, Enteroscopy-assisted & laparoscopy-assisted ERCP" and "altered surgical anatomy" were combined to identify relevant papers for inclusion. We identified 34 studies, comprising a total of 1848 advanced assisted ERCPs in patients with altered UGI anatomy from 12 different countries. These papers were critically appraised, summarised, and presented in table format. EDGE and LA-ERCP were associated with both the highest overall combined CBD cannulation rates (99.3% for both vs 74.6% for DEA-ERCP) and ERCP interventional success (98.3% for EDGE vs 97.4% for LA-ERCP and 67.6% for DEA-ERCP). Advanced ERCP is associated with excellent success rates and a higher safety profile than surgery; however, patient selection and identification of the exact surgical anatomy are key.
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Affiliation(s)
- Mohamed Elsharif
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK.
| | - Adam Gary Hague
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
| | - Hussam Ahmed
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
| | - Roger Ackroyd
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
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EUS-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE): The First Learning Curve. J Clin Gastroenterol 2020; 54:569-572. [PMID: 32149820 DOI: 10.1097/mcg.0000000000001326] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) is a minimally invasive option for pancreaticobiliary access in patients with Roux-en-Y anatomy. The procedure involves creating a fistulous tract between the remnant stomach or jejunum and the bypassed stomach with the deployment of a lumen-apposing metal stent (LAMS), followed by the advancement of an endoscope through the LAMS to perform an ERCP or EUS. It is a technically challenging procedure, requiring skills in EUS, fluoroscopy, and LAMS deployment. The aim of this study was to determine the learning curve for EDGE. METHODS Consecutive patients undergoing EDGE by a single operator were included from a prospective registry over 3 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum analyses were conducted for the learning curve. Technical success was defined as the successful creation of the fistulous tract. Clinical success was defined as successful EUS or ERCP via the LAMS. RESULTS Nineteen patients were included (21% male, mean age 58.7 y). Indication included symptomatic biliary stricture (n=6, 32%), choledocholithiasis (n=5, 26%), pancreatitis (n=3, 16%). Technical success was 100%. All patients had a 15 mm LAMS placed, 3 (16%) had cautery-enhanced LAMS. Clinical success was achieved in 18/19 (95%) patients. Fourteen patients had an ERCP, 1 patient had a EUS, and 3 patients had both. Adverse events included 2 cases of bleeding, 1 case of post-ERCP pancreatitis, and 1 jejunal perforation during duodenoscope insertion managed endoscopically.Median procedure time was 54.5 minutes (range: 31 to 88 min). Cumulative sum chart shows a 54-minute procedure time was achieved at the ninth procedure hence indicating efficiency. Apart from 2 outliers, the procedure duration further reduced with consequent procedures with the last 3 being under 40 minutes indicating that after 25 to 35 procedures a plateau may be reached indicating mastery (nonlinear regression P<0.0001). CONCLUSIONS Endoscopists experienced in EDGE are expected to achieve a reduction in procedure time over successive cases, with efficiency reached 54.5 minutes and a learning rate of 9 cases. After 25 to 35 procedures, a plateau may be reached indicating mastery.
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Ayoub F, Brar TS, Banerjee D, Abbas AM, Wang Y, Yang D, Draganov PV. Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis. Endosc Int Open 2020; 8:E423-E436. [PMID: 32118116 PMCID: PMC7035133 DOI: 10.1055/a-1070-9132] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/30/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy, which is increasing in frequency given the rise of obesity. Laparoscopy-assisted ERCP (LA-ERCP) and enteroscopy-assisted ERCP (EA-ERCP) are distinct approaches with their respective strengths and weaknesses. We conducted a meta-analysis comparing the procedural time, rates of success and adverse events of each method. Patients and methods A search of PubMed, EMBASE and the Cochrane library was performed from inception to October 2018 for studies reporting outcomes of LA or EA-ERCP in patients with RYGB anatomy. Studies using single, double, 'short' double-balloon or spiral enteroscopy were included in the EA-ERCP arm. Outcomes of interest included procedural time, papilla identification, papilla cannulation, therapeutic success and adverse events. Therapeutic success was defined as successful completion of the originally intended diagnostic or therapeutic indication for ERCP. Results A total of 3859 studies were initially identified using our search strategy, of which 26 studies met the inclusion criteria. The pooled rate of therapeutic success was significantly higher in LA-ERCP (97.9 %; 95 % CI: 96.7-98.7 %) with little heterogeneity (I 2 = 0.0 %) when compared to EA-ERCP (73.2 %; 95 % CI: 62.5-82.6 %) with significant heterogeneity (I 2 : 80.2 %). Conversely, the pooled rate of adverse events was significantly higher in LA-ERCP (19.0 %; 95 % CI: 12.6-26.4 %) when compared to EA-ERCP (6.5 %; 95% CI: 3.9-9.6 %). The pooled mean procedure time for LA-ERCP was 158.4 minutes (SD ± 20) which was also higher than the mean pooled procedure time for EA-ERCP at 100.5 minutes (SD ± 19.2). Conclusions LA-ERCP is significantly more effective than EA-ERCP in patients with RYGB but is associated with a higher rate of adverse events and longer procedural time.
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Affiliation(s)
- Fares Ayoub
- Section of Gastroenterology, Hepatology & Nutrition, University of Chicago, Illinois, United States
| | - Tony S. Brar
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Debdeep Banerjee
- Department of Medicine, University of Florida, Gainesville, Florida, United States
| | - Ali M. Abbas
- Brigham and Women's Hospital, Division of Gastroenterology, Harvard Medical School, Boston, Massachusetts, United States
| | - Yu Wang
- Department of Biostatistics, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States,Corresponding author Peter V. Draganov, MD Professor of MedicineDivision of Gastroenterology, Hepatology & NutritionUniversity of Florida1329 SW 16th StreetGainesville, FL 32608+1-352-627-9002
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Strong AT, Kroh M. Management of Common Bile Duct Stones in the Presence of Prior Roux-en-Y. THE SAGES MANUAL OF BILIARY SURGERY 2020:241-263. [DOI: 10.1007/978-3-030-13276-7_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Jovani M, Ichkhanian Y, Vosoughi K, Khashab MA. EUS-guided biliary drainage for postsurgical anatomy. Endosc Ultrasound 2019; 8:S57-S66. [PMID: 31897381 PMCID: PMC6896432 DOI: 10.4103/eus.eus_53_19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/15/2019] [Indexed: 12/19/2022] Open
Abstract
ERCP is the mainstay of therapy for pancreatobiliary diseases in patients with native upper gastrointestinal (UGI) anatomy. However, when UGI anatomy is surgically altered, standard ERCP becomes technically challenging or not possible. In such instances, EUS-guided biliary drainage (EUS-BD) has been increasingly employed by advanced endoscopists as a safe and effective method of access to the biliary tree. In this study, we review the technical aspects and outcomes of EUS-BD in patients with surgical UGI anatomy.
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Affiliation(s)
- Manol Jovani
- Clinical and Translational Epidemiology Unit, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA.,Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Abstract
BACKGROUND Trans-oral endoscopic access to the pancreaticobiliary system is challenging after Roux-en-Y gastric bypass (RYGB). Trans-gastric ERCP (TG-ERCP) has emerged as a viable option to manage patients with symptomatic post-RYBG choledocolithiasis. The aim of this systematic review and meta-analysis was to examine the outcomes of TG-ERCP to better define the risk-benefit ratio of this procedure and to guide clinical decision-making. METHODS A literature search was conducted to identify all reports on ERCP after RYGB. Pubmed, MEDLINE, Embase, and Cochrane databases were thoroughly consulted matching the terms "ERCP" AND "gastric bypass." Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were calculated using Freeman-Tukey double arcsine transformation and DerSimonian-Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I2-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders. RESULTS Thirteen papers published between 2009 and 2017 matched the inclusion criteria. Eight hundred fifty patients undergoing 931 procedures were included. The most common clinical indications for TG-ERCP were biliary (90%) and pancreatic (10%). The majority of patients underwent an initial laparoscopic approach (90%). Same-day ERCP was successfully achieved in 703 cases (75.5%). Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were 99% (95% CI = 98-100%), 3.1% (95% CI = 1.0-5.8%), 3.4% (95% CI = 1.7-5.5%), and 14.2% (95% CI = 8.5-20.8%), respectively. CONCLUSION TG-ERCP is a safe and effective therapeutic option in patients with symptomatic post-RYGB choledocolithiasis.
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Tzedakis S, Memeo R, Nedelcu M, Rodriguez M, Delvaux M, Huppertz J, Jeddou H, Mutter D, Marescaux J, Pessaux P. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography: Preliminary experience and technique description. J Visc Surg 2019; 156:381-386. [PMID: 30885707 DOI: 10.1016/j.jviscsurg.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Common bile duct lithiasis after Roux-en-Y gastric bypass (RYGB) or upper gastrointestinal stenosis has become a challenging problem nowadays, especially as obesity surgery is increasing. In this study, we assess the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) and describe its technique. METHODS A retrospective review of a prospectively collected database of consecutive patients undergoing a LAERCP between February 2014 and May 2015 was performed at a single institution. Indications were common bile duct lithiasis associated with acute or past episodes of cholangitis and pancreatitis. Endoscopic access to the gastric remnant was obtained laparoscopically. RESULTS In total 5 cases were identified. Four of them had undergone a RYGB and one of them presented a benign esophageal peptic stenosis, not allowing peroral gastric access. Biliary cannulation using LAERCP associated with sphincterotomy and stone extraction was successfully achieved in all patients. Mean duration of the entire procedure was 134minutes (range: 66-200min). No early major complications were observed and the mean postoperative hospital stay was 4 days (range: 2-5 days). CONCLUSIONS LAERCP is a safe and successful procedure for the treatment of common bile duct lithiasis when conventional biliary access is not feasible, notably after RYGB. Larger trials still need to be performed to evaluate efficacy, technical success, and complications related to this technique.
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Affiliation(s)
- S Tzedakis
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
| | - R Memeo
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; IHU-Strasbourg, institute for image-guided surgery, 67000 Strasbourg, France; Department of Emergency and Organ Transplantation, University of Bari, 70100 Bari, Italy.
| | - M Nedelcu
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
| | - M Rodriguez
- Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
| | - M Delvaux
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
| | - J Huppertz
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
| | - H Jeddou
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
| | - D Mutter
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; IHU-Strasbourg, institute for image-guided surgery, 67000 Strasbourg, France; Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
| | - J Marescaux
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; IHU-Strasbourg, institute for image-guided surgery, 67000 Strasbourg, France
| | - P Pessaux
- IRCAD, Research institute against cancer of the digestive system, 67000 Strasbourg, France; IHU-Strasbourg, institute for image-guided surgery, 67000 Strasbourg, France; Department of digestive surgery, university hospital of Strasbourg, 67000 Strasbourg, France
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Schwartz PB, Easler JJ, Lancaster WP, House MG, Zyromski NJ, Schmidt C, Nakeeb A, Ceppa EP. Sphincter of Oddi Dysfunction After Gastric Bypass: Surgical or Endoscopic Therapy? J Surg Res 2019; 238:41-47. [DOI: 10.1016/j.jss.2019.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/27/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022]
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12
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Ivano FH, Ponte BJ, Dubik TC, Ivano VK, Winkeler VLL, Kay AK. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP): ANALYSIS OF THE EFFECTIVENESS AND SAFETY OF THE PROCEDURE IN THE PATIENT WITH ROUX-EN-Y GASTRIC BYPASS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2019; 32:e1432. [PMID: 31038557 PMCID: PMC6488270 DOI: 10.1590/0102-672020190001e1432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/16/2019] [Indexed: 01/22/2023]
Abstract
Background: Obesity can be treated with bariatric surgery; but, excessive weight loss
may lead to diseases of the bile duct such as cholelithiasis and
choledocholithiasis. Endoscopic retrograde cholangiopancreatography is a
diagnostic and therapeutic procedure for these conditions, and may be
hampered by the anatomical changes after surgery. Aim: Report the efficacy and the safety of videolaparoscopy-assisted endoscopic
retrograde cholangiopancreatography technique in patients after bariatric
surgery with Roux-en-Y gastric bypass. Method: Retrospective study performed between 2007 and 2017. Data collected were:
age, gender, surgical indication, length of hospital stay, etiological
diagnosis, rate of therapeutic success, intra and postoperative
complications. Results: Seven patients had choledocholithiasis confirmed by image exam, mainly in
women. The interval between gastric bypass and endoscopic procedure ranged
from 1 to 144 months. There were no intraoperative complications. The rate
of duodenal papillary cannulation was 100%. Regarding complications, the
majority of cases were related to gastrostomy, and rarely to endoscopic
procedure. There were two postoperative complications, a case of
chest-abdominal pain refractory to high doses of morphine on the same day of
the procedure, and a laboratory diagnosis of acute pancreatitis after the
procedure in an asymptomatic patient. The maximum hospital stay was four
days. Conclusion: The experience with endoscopic retrograde cholangiopancreatography through
laparoscopic gastrostomy is a safe and effective procedure, since most
complications are related to the it and did not altered the sequence to
perform the conventional cholangiopancreatography.
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Affiliation(s)
- Flávio Heuta Ivano
- Pontificate Catholic University of Paraná, Medicine.,Service of Digestive Endoscopy, Sugisawa Hospital, Curitiba, PR, Brasil
| | | | | | | | | | - Antônio Katsumi Kay
- Pontificate Catholic University of Paraná, Medicine.,Service of Digestive Endoscopy, Sugisawa Hospital, Curitiba, PR, Brasil
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13
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Kedia P, Tarnasky PR. Endoscopic Management of Complex Biliary Stone Disease. Gastrointest Endosc Clin N Am 2019; 29:257-275. [PMID: 30846152 DOI: 10.1016/j.giec.2018.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Choledocholithiasis is a common disorder that is managed universally by endoscopic retrograde cholangiopancreatography (ERCP). For difficult or complex stones, ERCP with conventional techniques may fail to achieve biliary clearance in 10% to 15% of cases. This review summarizes the literature regarding the current available endoscopic techniques for complex stone disease, including mechanical lithotripsy, endoscopic papillary large balloon dilation, cholangioscopy-guided lithotripsy, and endoscopic ultrasound-guided biliary access.
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Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology, Department of Medicine, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Pavillion II, Suite 630, Dallas, TX 75208, USA.
| | - Paul R Tarnasky
- Division of Gastroenterology, Department of Medicine, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Pavillion II, Suite 630, Dallas, TX 75208, USA
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14
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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. [PMID: 29668560 DOI: 10.1097/mcg.0000000000001037] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The standard of care for managing pancreaticobiliary disease in altered Roux-en-Y gastric bypass patients is laparoscopy-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP), but is limited by cost and adverse events. Recently a minimally invasive, completely endoscopic approach using endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) has been described. We aim to compare EDGE to LA-ERCP in this study. METHODS Patients from May 2005 to June 2017 with Roux-en-Y gastric bypass anatomy having undergone LA-ERCP or EDGE at 4 tertiary centers were captured in a registry. Patient demographics, procedural details, and clinical outcomes were measured for each group. RESULTS Seventy-two patients (n=29 EDGE, n=43 LA-ERCP) were included in this study. There was no significant difference in the technical success of EDGE gastrogastric fistula (96.5%) versus LA-gastrostomy creation (100%). The success rate of achieving therapeutic ERCP (EDGE 96.5% vs. LA-ERCP 97.7%) and number of ERCP (EDGE 1.2 vs. LA-ERCP 1.02) needed to achieve clinical resolution was similar between both groups. Adverse event rate for EDGE, 24% (7/29) and LA-ERCP, 19% (8/43) was similar. The total procedure time (73 vs. 184 min) and length of hospital stay (0.8 vs. 2.65 d) was significantly shorter for EDGE compared to LA-ERCP. The overall weight change after EDGE was -6.6 lbs at an average 28-week follow-up. CONCLUSIONS This study suggests that the EDGE procedure has similar technical success and adverse events compared with LA-ERCP with the benefit of significantly shorter procedure times and hospital stay. EDGE may offer a minimally invasive, effective option, with less resource utilization, and without significant weight gain.
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15
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Maple JT. Preparation of the Patient for ERCP. ERCP 2019:80-85.e3. [DOI: 10.1016/b978-0-323-48109-0.00010-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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16
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Arapis K, Donatelli G, Tammaro P, Ribeiro Parenti L, Marmuse JP, Hansel B. Janeway Gastrostomy for Trans-gastric ERCP: an Emergency Alternative Method to Access the Excluded Structures. Obes Surg 2018; 28:2916-2917. [PMID: 29909513 DOI: 10.1007/s11695-018-3349-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Konstantinos Arapis
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France. .,Paris Diderot University-Sorbonne Paris Cité, Paris, France.
| | - Gianfranco Donatelli
- Department of Gastroenterology and Hepatology, Hôpital Privé des Peupliers, 8 place de l'Abbé G. Hénocque, 75013, Paris, France
| | - Pascuale Tammaro
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France
| | - Lara Ribeiro Parenti
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Jean Pierre Marmuse
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Boris Hansel
- Paris Diderot University-Sorbonne Paris Cité, Paris, France.,Department of Endocrinology, Diabetology, Nutrition, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48 rue Henri Hussard, 75018, Paris, France
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17
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Ligresti D, Amata M, Granata A, Cipolletta F, Barresi L, Traina M, Tarantino I. Single Session EUS-Guided Temporary Gastro-Gastrostomy and ERCP Following Gastric Bypass. Obes Surg 2018; 28:886-888. [DOI: 10.1007/s11695-017-3097-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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18
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Treatment of Common Bile Duct Stones in Gastric Bypass Patients with Laparoscopic Transgastric Endoscopic Retrograde Cholangiopancreatography. Obes Surg 2017; 27:1409-1413. [PMID: 28054294 DOI: 10.1007/s11695-016-2524-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass excludes the biliary tree from traditional evaluation and treatment with endoscopic retrograde cholangiopancreatography (ERCP). Due to the initial rapid weight loss, gastric bypass patients have an increased risk of developing gallstones in the gallbladder as well as in the common bile duct. Various techniques to access the biliary tree have been described. The techniques are characterised by complexity and varying results. The aim of the present study was to assess both feasibility and outcome of laparoscopic-assisted transgastric ERCP in patients with gastric bypass. METHODS We retrospectively reviewed all laparoscopic transgastric ERCPs performed at Zealand University Hospital during the period January 2010 to January 2016. The main outcome was cannulation of the common bile duct. Secondary outcomes were length of hospital stay and surgical complications. RESULTS Thirty-one laparoscopic assisted transgastric ERCP procedures were performed in 29 patients. Indication was choledocholithiasis. All planned procedures were conducted with a 100% success in cannulation of the common bile duct. Median hospital stay was 2 days (range 1-22). Perforation of the wall of the gastric remnant occurred in two patients. The overall postoperative complication rate was 36%. Surgical complications were bleeding, haematoma and intra-abdominal abscesses. CONCLUSION Laparoscopic assisted transgastric ERCP is feasible, but there are several complications related to the procedure. Thus, until better alternative treatments are developed, it is recommended that the procedure should be performed at centres with both high endoscopic and bariatric expertise.
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19
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Verscheure D, Gianfranco D, Tammaro P, Dumont JL, Marmuse JP, Arapis K. Access to excluded structures after Roux-en-Y gastric bypass: Experience in a high-level bariatric center without a technical platform for endoscopic retrograde cholangiopancreatography. J Visc Surg 2017; 155:195-200. [PMID: 29221786 DOI: 10.1016/j.jviscsurg.2017.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rapid weight loss after bariatric surgery is associated with a high prevalence of gallstone formation. In laparoscopic Roux-en-Y gastric bypass (RYGBP), the bypassed segment is not readily available for endoscopic or radiographic examination. We propose a laparoscopic Janeway gastrostomy for secondary access to excluded structures in bariatric centers with no mandatory technical equipment in endoscopic retrograde cholangiopancreatography (ERCP), double-balloon ERCP or spiral enteroscopy. METHOD This was a single-institution retrospective review of a prospectively collected database of patients with a history of laparoscopic RYGBP who underwent laparoscopic Janeway gastrostomy for duodenal and biliary access. The operative indications, technical aspects, endoscopic findings, outcomes, and complications were investigated. RESULTS Five patients with a history of RYGBP underwent laparoscopic Janeway gastrostomy for exploration of the bypassed segment. All of them had biliary pathology, and all underwent successful ERCP and papillotomy. The gastrostomies were closed secondarily. The mean duration of hospitalization was 12 days. No complications developed. All procedures were performed laparoscopically. CONCLUSION If access to excluded structures and simultaneous ERCP was not possible, temporary laparoscopic Janeway gastrostomy could be the last option alternative for a staged ERCP to gain access to the bypassed structures. It is a feasible and safe solution for the exploration and treatment of patients with a history of RYGBP in bariatric centers that have no endoscopists with expertise in ERCP.
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Affiliation(s)
- D Verscheure
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
| | - D Gianfranco
- Department of gastroenterology and hepatology, hôpital privé des Peupliers, 8, place de l'Abbé G.-Hénocque, 75013 Paris, France.
| | - P Tammaro
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
| | - J L Dumont
- Department of gastroenterology and hepatology, hôpital privé des Peupliers, 8, place de l'Abbé G.-Hénocque, 75013 Paris, France.
| | - J P Marmuse
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
| | - K Arapis
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
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20
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Richardson JF. Paired editorial: Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2017; 13:1242-1244. [PMID: 28755890 DOI: 10.1016/j.soard.2017.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 03/30/2017] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
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21
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Lim CH, Jahansouz C, Freeman ML, Leslie DB, Ikramuddin S, Amateau SK. Outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) and Sphincterotomy for Suspected Sphincter of Oddi Dysfunction (SOD) Post Roux-En-Y Gastric Bypass. Obes Surg 2017; 27:2656-2662. [PMID: 28488091 DOI: 10.1007/s11695-017-2696-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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22
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Bank JS, Adler DG. Lumen apposing metal stents: A review of current uses and outcomes. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jeffrey S. Bank
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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23
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Souto-Rodríguez R, Alvarez-Sánchez MV. Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results. World J Gastrointest Endosc 2017; 9:105-126. [PMID: 28360973 PMCID: PMC5355758 DOI: 10.4253/wjge.v9.i3.105] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/12/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.
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24
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Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol 2017; 52:276-300. [PMID: 27942871 DOI: 10.1007/s00535-016-1289-7] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 02/08/2023]
Abstract
Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.
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25
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Yang D, DiMaio CJ. Interventional endoscopy. BLUMGART'S SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS, 2-VOLUME SET 2017:511-524.e4. [DOI: 10.1016/b978-0-323-34062-5.00029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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26
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Tyberg A, Nieto J, Salgado S, Weaver K, Kedia P, Sharaiha RZ, Gaidhane M, Kahaleh M. Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: Mid-Term Analysis of an Emerging Procedure. Clin Endosc 2016; 50:185-190. [PMID: 27642849 PMCID: PMC5398356 DOI: 10.5946/ce.2016.030] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/27/2016] [Indexed: 12/14/2022] Open
Abstract
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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Affiliation(s)
- Amy Tyberg
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, NY, USA
| | - Jose Nieto
- Division of Gastroenterology and Hepatology, Borland-Groover Clinic (BGC), Jacksonville, FL, USA
| | - Sanjay Salgado
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, NY, USA
| | - Kristen Weaver
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, NY, USA
| | - Prashant Kedia
- Interventional Endoscopy, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, NY, USA
| | - Monica Gaidhane
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, NY, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York, NY, USA
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Martin A, Kistler CA, Wrobel P, Yang JF, Siddiqui AA. Endoscopic ultrasound-guided pancreaticobiliary intervention in patients with surgically altered anatomy and inaccessible papillae: A review of current literature. Endosc Ultrasound 2016; 5:149-56. [PMID: 27386471 PMCID: PMC4918297 DOI: 10.4103/2303-9027.183969] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The management of pancreaticobiliary disease in patients with surgically altered anatomy is a growing problem for gastroenterologists today. Over the years, endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the treatment of pancreaticobiliary disease. Patient anatomy has become increasingly complex due to advances in surgical resection of pancreaticobiliary disease and EUS has emerged as the therapy of choice when endoscopic retrograde cholangiopancreatography failed cannulation or when the papilla is inaccessible such as in gastric obstruction or duodenal obstruction. The current article gives a comprehensive review of the current literature for EUS-guided intervention of the pancreaticobiliary tract in patients with altered surgical anatomy.
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Affiliation(s)
- Aaron Martin
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Charles Andrew Kistler
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Piotr Wrobel
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Juliana F Yang
- Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ali A Siddiqui
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
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28
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Enestvedt BK, Kothari S, Pannala R, Yang J, Fujii-Lau LL, Hwang JH, Konda V, Manfredi M, Maple JT, Murad FM, Woods KL, Banerjee S. Devices and techniques for ERCP in the surgically altered GI tract. Gastrointest Endosc 2016; 83:1061-75. [PMID: 27103361 DOI: 10.1016/j.gie.2016.03.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/04/2016] [Indexed: 02/08/2023]
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29
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Bowman E, Greenberg J, Garren M, Guda N, Rajca B, Benson M, Pfau P, Soni A, Walker A, Gopal D. Laparoscopic-assisted ERCP and EUS in patients with prior Roux-en-Y gastric bypass surgery: a dual-center case series experience. Surg Endosc 2016; 30:4647-52. [PMID: 26823057 DOI: 10.1007/s00464-016-4746-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/02/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with Roux-en-Y gastric bypass (RYGB) develop pancreatobiliary issues after surgery. Endoscopic management via the conventional route with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) is quite limited due to the altered anatomy. Laparoscopic-assisted ERCP (LA-ERCP) via the excluded stomach has been highly successful. Reported use of laparoscopic-assisted EUS (LA-EUS) is extremely rare. METHODS A retrospective review was conducted at two tertiary referral centers for cases that involved laparoscopic-assisted ERCP and EUS. Patient demographic data were collected along with data regarding procedure, indication, complications and length of stay. RESULTS A total of 16 cases involving 15 patients were identified: 11 cases of LA-ERCP and five cases of combined LA-EUS plus LA-ERCP were performed. Four patients had previously undergone failed endoscopy via the conventional route (27 %). There was a 100 % biliary/pancreatic cannulation and intervention rate. There were no endoscopic-related complications. Therapeutic interventions included laparoscopic cholecystectomy, lysis of adhesions, biliary and pancreatic sphincterotomy, biliary and pancreatic stent placement, stone removal including mechanical lithotripsy and EUS biopsy and diagnosis of pancreatic cancer. Average discharge was on postoperative day 3.4. However, 50 % were discharged after 1 day. CONCLUSIONS LA-ERCP and combined LA-EUS plus LA-ERCP are safe and highly successful diagnostic and therapeutic modalities for a wide variety of pancreatobiliary ailments in RYGB patients.
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Affiliation(s)
- Erik Bowman
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Wisconsin Hospital & Clinics, 1685 Highland Ave, Madison, WI, 53705, USA.
| | - Jacob Greenberg
- Department of Surgery, University of Wisconsin Hospital & Clinics, Madison, WI, USA
| | - Michael Garren
- Department of Surgery, University of Wisconsin Hospital & Clinics, Madison, WI, USA
| | - Nalini Guda
- Division of Gastroenterology, Aurora St. Lukes Medical Center, Milwaukee, WI, USA
| | - Brian Rajca
- Division of Gastroenterology, Aurora St. Lukes Medical Center, Milwaukee, WI, USA
| | - Mark Benson
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Wisconsin Hospital & Clinics, 1685 Highland Ave, Madison, WI, 53705, USA
| | - Patrick Pfau
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Wisconsin Hospital & Clinics, 1685 Highland Ave, Madison, WI, 53705, USA
| | - Anurag Soni
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Wisconsin Hospital & Clinics, 1685 Highland Ave, Madison, WI, 53705, USA
| | - Andrew Walker
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Wisconsin Hospital & Clinics, 1685 Highland Ave, Madison, WI, 53705, USA
| | - Deepak Gopal
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Wisconsin Hospital & Clinics, 1685 Highland Ave, Madison, WI, 53705, USA
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Brockmeyer JR, Grover BT, Kallies KJ, Kothari SN. Management of biliary symptoms after bariatric surgery. Am J Surg 2015; 210:1010-6; discussion 1016-7. [DOI: 10.1016/j.amjsurg.2015.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/21/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
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Snauwaert C, Laukens P, Dillemans B, Himpens J, De Looze D, Deprez PH, Badaoui A. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients. Endosc Int Open 2015; 3:E458-63. [PMID: 26528502 PMCID: PMC4612229 DOI: 10.1055/s-0034-1392108] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/02/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Performing endoscopic retrograde cholangiopancreatography in bariatric patients who underwent Roux-en-Y gastric bypass surgery is challenging due to the long anatomical route required to reach the biliopancreatic limb. AIM Assessment of the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography. METHODS A retrospective multicenter observational consecutive-patient cohort study of all patients in the period May 2008 to September 2014 with a history of Roux-en-Y gastric bypass who presented with complicated biliary disease and who underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography. The laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure was similar in all centers and was performed through a 15 mm or 18 mm trocar that was inserted in the gastric remnant. Cholecystectomy was performed concomitantly when indicated. RESULTS In total, 23 patients underwent a laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography procedure. Two patients required a mini-laparotomy for transgastric access because of a complex surgical history resulting in multiple adhesions. Indications included ascending cholangitis, choledocholithiasis, and biliary pancreatitis. Of the 23 patients, 13 underwent concomitant cholecystectomy. All patients successfully underwent biliary cannulation and sphincterotomy. No endoscopic procedure-related complications (i. e. bleeding, pancreatitis or retroperitoneal perforation) occurred. Mean hospital stay was 2.8 days (range 2 - 4). CONCLUSIONS Transgastric endoscopic retrograde cholangiopancreatography is a feasible approach in the treatment of pancreaticobiliary disease in Roux-en-Y gastric bypass patients, without major complications in our series and allows endoscopic treatment and cholecystectomy to be performed consecutively in a single procedure. In Roux-en-Y gastric bypass patients without a history of prior cholecystectomy presenting with complicated gallstone disease, combining cholecystectomy and transgastric endoscopic retrograde cholangiopancreatography as a first-line approach may be a valid treatment strategy.
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Affiliation(s)
- Christophe Snauwaert
- Cliniques Universitaires Saint-Luc, Brussels, Belgium,AZ Sint-Jan Hospital Brugge-Oostende, Bruges, Belgium,Corresponding author Christophe Snauwaert, MD Dudzeelse Steenweg 1498000 BruggeBelgium+32-2-7648927
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Abstract
PURPOSE OF REVIEW Bariatric surgery is recognized as the most effective treatment against obesity as it results in significant weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. This review illustrates the latest developments in the endoscopic management of bariatric surgical complications. RECENT FINDINGS For successful management of complications, precipitating and perpetuating factors must be addressed in addition to directing therapy at the target pathology. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Chronic proximal staple-line leaks/fistulas frequently do not respond to primary closure with diversion therapy, and a new technique of stricturotomy has been reported to improve outcomes. Innovations in the field of transoral endoscopic instruments have led to the development of a single-session entirely internal endoscopic retrograde cholangiopancreatography by creating a gastrogastric anastomosis. SUMMARY Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention. Computed tomography-guided drainage may be necessary in patients with drainable fluid collections. VIDEO ABSTRACT http://links.lww.com/COG/A11.
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Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ, Kahaleh M. EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc 2015; 82:560-5. [PMID: 25952086 DOI: 10.1016/j.gie.2015.03.1913] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/09/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND ERCP is challenging in patients with Roux-en-Y gastric bypass. Using EUS to gain access to the excluded stomach and subsequently performing transcutaneous ERCP was described recently. OBJECTIVE We describe our initial experience with an internal EUS-directed transgastric ERCP (EDGE) procedure by using a lumen-apposing metal stent (LAMS). DESIGN Single-center case series. SETTING Tertiary center with expertise in EUS-guided procedures. PATIENTS Five patients with Roux-en-Y gastric bypass underwent EDGE via a LAMS. INTERVENTIONS A linear echoendoscope was used to access the excluded stomach. A LAMS was deployed over a wire to create a gastrogastric or jejunogastric fistula. A duodenoscope was then passed through the LAMS and conventional ERCP was performed. MAIN OUTCOME MEASUREMENTS Technical and clinical success rates as well as adverse events. RESULTS EUS-guided creation of a gastrogastric or jejunogastric fistula via placement of a LAMS was successful in all cases (100%). The ability to perform ERCP through the fashioned fistula during the index procedure was successful in 3 of 5 cases (60%). Two LAMS dislodgments requiring restenting were observed. No major adverse events were observed. No weight regain occurred. The median procedure time was 68.0 minutes. LIMITATIONS Small sample, single-institution experience. CONCLUSION The internal EDGE procedure may offer a cost-effective, minimally invasive option for a common problem in a growing patient demographic. Further refinement of the technique is required to minimize adverse events. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01522573.).
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Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Amy Tyberg
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Nikhil A Kumta
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Monica Gaidhane
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Kunal Karia
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
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Yamauchi H, Kida M, Imaizumi H, Okuwaki K, Miyazawa S, Iwai T, Koizumi W. Innovations and techniques for balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy. World J Gastroenterol 2015; 21:6460-6469. [PMID: 26074685 PMCID: PMC4458757 DOI: 10.3748/wjg.v21.i21.6460] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/24/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine. Recently, many studies have reported that balloon-enteroscope-assisted ERCP (BEA-ERCP) is a safe and effective procedure. However, further improvements in outcomes and the development of simplified procedures are required. Percutaneous treatment, Laparoscopy-assisted ERCP, endoscopic ultrasound-guided anterograde intervention, and open surgery are effective treatments. However, treatment should be noninvasive, effective, and safe. We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications. BEA-ERCP still requires high expertise-level techniques and is far from a routinely performed procedure. Various techniques have been proposed to facilitate scope insertion (insertion with percutaneous transhepatic biliary drainage (PTBD) rendezvous technique, Short type single-balloon enteroscopes with passive bending section, Intraluminal injection of indigo carmine, CO2 inflation guidance), cannulation (PTBD or percutaneous transgallbladder drainage rendezvous technique, Dilation using screw drill, Rendezvous technique combining DBE with a cholangioscope, endoscopic ultrasound-guided rendezvous technique), and treatment (overtube-assisted technique, Short type balloon enteroscopes) during BEA-ERCP. The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients. A standard procedure for ERCP yet to be established for patients with a reconstructed intestine. At present, BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as first-line treatment. In this article, we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.
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Molina Romero FX, Morón Canis JM, Llompart Rigo A, Rodríguez Pino JC, Morales Soriano R, González Argente FX. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography after biliopancreatic diversion. Cir Esp 2015; 93:594-8. [PMID: 26025065 DOI: 10.1016/j.ciresp.2015.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/26/2015] [Accepted: 03/13/2015] [Indexed: 10/23/2022]
Abstract
Endoscopic retrograde cholangiopancreatography may be difficult in patients that have undergone Roux-en-Y gastric bypass. Due to the fact that prevalence of morbid obesity is increasing, and laparoscopic procedures for its treatment have increased, the incidence of biliary tract problems in patients of altered anatomy is also growing. We describe a laparoscopic technique to access the biliary tree by endoscope, through the excluded stomach.
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Affiliation(s)
- Francesc Xavier Molina Romero
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España.
| | - José Miguel Morón Canis
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Alfredo Llompart Rigo
- Servicio de Digestivo, Unidad de Endoscopia Digestiva, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - José Carlos Rodríguez Pino
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Rafael Morales Soriano
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Francesc Xavier González Argente
- Servicio de Cirugía General y del Aparato Digestivo, Unidad Hepatobiliopancreática, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
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Kedia P, Sharaiha RZ, Kahaleh M. Reply: To PMID 24975458. Gastroenterology 2015; 148:859. [PMID: 25726744 DOI: 10.1053/j.gastro.2015.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
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Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc 2014; 29:1753-9. [DOI: 10.1007/s00464-014-3901-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 09/12/2014] [Indexed: 01/26/2023]
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Kedia P, Sharaiha RZ, Kumta NA, Kahaleh M. Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology 2014; 147:566-8. [PMID: 24975458 DOI: 10.1053/j.gastro.2014.05.045] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 05/12/2014] [Accepted: 05/19/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Prashant Kedia
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | - Nikhil A Kumta
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York.
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Cosgrove ND, Wang AY. Endoscopic approaches to biliary intervention in patients with surgically altered gastroduodenal anatomy. World J Surg Proced 2014; 4:23-32. [DOI: 10.5412/wjsp.v4.i2.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/01/2014] [Accepted: 03/18/2014] [Indexed: 02/06/2023] Open
Abstract
Over the past decade the ability of endoscopists to access the biliary tree in patients with surgically altered gastroduodenal anatomy has significantly advanced. Much of the progress has occurred as a result of the development of better tools to navigate the deep small bowel, such as single-balloon- (SBE), double-balloon- (DBE), and spiral-enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP). However, despite using a cap, accessing the papilla or bile duct using these forward-viewing enteroscopy platforms remains challenging, even in expert hands. In patients with Roux-en-Y gastric bypass (RYGB) anatomy, the excluded stomach is a potential point of access for either a delayed transgastric- or immediate laparoscopy-assisted-ERCP approach. However, the parallel advancement of therapeutic endoscopic ultrasound (EUS) also provides alternative approaches through which the biliary system can be accessed and intervened on in patients with surgically altered anatomies. Generally speaking, in patients with short gastro-jejunal “Roux” and bilio-pancreatic limbs, ideally less than 150 cm in length, starting with a (cap-assisted) push-enteroscopy or balloon-enteroscopy approach would offer reasonable diagnostic and therapeutic ERCP success. When available, short-SBE or short-DBE scopes should be used, as they allow the use of conventional ERCP equipment, are associated with shorter procedure times, and are easier to manipulate. In patients with RYGB who have longer Roux and/or bilio-pancreatic limbs (> 150 cm in total length), or in patients who have failed prior attempts at deep enteroscopy-assisted ERCP, transgastric laparoscopy-assisted-ERCP is associated with higher rates of diagnostic and therapeutic success as compared to deep-enteroscopy-assisted ERCP. Finally, EUS-guided biliary access for antegrade biliary intervention or for rendezvous enteroscopy-assisted ERCP is possible. While percutaneous transhepatic biliary drainage and surgical bile duct exploration remain viable alternatives, these methods are not without significant morbidity and mortality and should only be considered if less invasive endoscopic interventions are not feasible or appropriate.
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Navarra G, La Malfa G, Lazzara S, Centorrino T, De Marco ML, Currò G. Reversible bilio-pancreatic diversion with explorable excluded stomach-the Messina technique. Obes Surg 2014; 24:1563-6. [PMID: 24898722 DOI: 10.1007/s11695-014-1324-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The authors propose a reversible bilio-pancreatic diversion with access to the bypassed stomach. In the Messina technique, bilio-pancreatic diversion is accomplished by transecting the stomach without gastric resection, as already described by Resa et al. In addition, a temporary gastrostomy is performed on the excluded stomach and allows direct postoperative exploration of the duodenum and the biliary tree. The Messina bilio-pancreatic diversion technique (MBPDT) seems to be safe and effective. The authors propose the MBPDT in a morbidly obese patient undergoing bariatric surgery when a malabsorptive operation is required, as it makes the original Scopinaro operation reversible, the bilio-pancreatic area explorable postoperatively, the operation shorter, and does not cause any significant increase in the postoperative complication rate. Larger numbers and longer follow-up, however, are needed to further confirm our data.
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Affiliation(s)
- Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
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Abstract
Biliary disease is common in the obese population and increases after bariatric surgery. This article reviews management of the gallbladder at the time of bariatric surgery, as well as imaging modalities in the bariatric surgery population and prevention of lithogenesis in the rapid weight loss phase. In addition, diagnosis and treatment options for biliary diseases are discussed, including laparoscopic-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography in the patient having bariatric surgery.
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Affiliation(s)
- Brandon T Grover
- Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA
| | - Shanu N Kothari
- Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA.
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ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013. [PMID: 23793801 DOI: 10.1007/s00464-013-3129-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy. METHODS Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician. RESULTS Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p < 0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022). CONCLUSIONS GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.
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Choi EK, Chiorean MV, Coté GA, El Hajj II, El Hajj I, Ballard D, Fogel EL, Watkins JL, McHenry L, Sherman S, Lehman GA. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013; 27:2894-9. [PMID: 23793801 DOI: 10.1007/s00464-013-2850-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 01/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy. METHODS Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician. RESULTS Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p < 0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022). CONCLUSIONS GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.
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Affiliation(s)
- Eun Kwang Choi
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN 46202, USA
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Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, Bakis G, Jonnalagadda SS, Al-Lehibi AA, Hardy A, Morgan DR, Sethi A, Stevens PD, Akerman PA, Thakkar SJ, Brauer BC. 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. [PMID: 23290720 DOI: 10.1016/j.gie.2012.10.015] [Citation(s) in RCA: 199] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 10/20/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Data on overtube-assisted enteroscopy to facilitate ERCP in patients with surgically altered pancreaticobiliary anatomy, or long-limb surgical bypass, is limited. OBJECTIVE To evaluate and compare ERCP success by using single-balloon (SBE), double-balloon (DBE), or rotational overtube enteroscopy. DESIGN Consecutive patients identified retrospectively. SETTING Eight U.S. referral centers. PATIENTS Long-limb surgical bypass patients with suspected pancreaticobiliary diseases. INTERVENTION Overtube-assisted enteroscopy ERCP. MAIN OUTCOME MEASUREMENTS Enteroscopy success: visualizing the pancreaticobiliary-enteric anastomosis or papilla. ERCP success: completing the intended pancreaticobiliary intervention. Clinical success: greater than 50% reduction in abdominal pain or level of hepatic enzyme elevations or resolution of jaundice. RESULTS From January 2008 through October 2009, 129 patients had 180 enteroscopy-ERCPs. Anatomy was Roux-en-Y: gastric bypass (n = 63), hepaticojejunostomy (n = 45), postgastrectomy (n = 6), Whipple procedure (n = 10), and other (n = 5). ERCP success was 81 of 129 (63%). Enteroscopy success: 92 of 129 (71%), of whom 81 of 92 (88%) achieved ERCP success. Reasons for ERCP failure (n = 48): afferent limb entered but pancreaticobiliary anastomosis and/or papilla not reached (n = 23), cannulation failure (n = 11), afferent limb angulation (n = 8), and jejunojejunostomy not identified (n = 6). Select interventions: anastomotic stricturoplasty (cautery ± dilation, n = 16), stone removal (n = 21), stent (n = 25), and direct cholangioscopy (n = 11). ERCP success rates were similar between Roux-en-Y gastric bypass and other long-limb surgical bypass and among SBE, DBE, and rotational overtube enteroscopy. Complications were 16 of 129, 12.4%. LIMITATIONS Retrospective study. CONCLUSION (1) ERCP is successful in nearly two-thirds of long-limb surgical bypass patients and in 88% when the papilla or pancreaticobiliary-enteric anastomosis is reached. (2) Enteroscopy success in long-limb surgical bypass is similar among SBE, DBE, and rotational overtube enteroscopy methods. (3) Referral of long-limb surgical bypass patients who require ERCP to high-volume institutions may be considered before more invasive percutaneous or surgical alternatives.
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Affiliation(s)
- Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
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Lee A, Shah JN. Endoscopic approach to the bile duct in the patient with surgically altered anatomy. Gastrointest Endosc Clin N Am 2013; 23:483-504. [PMID: 23540972 DOI: 10.1016/j.giec.2012.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy can be technically challenging, because of three main problems that must be overcome: (1) endoscopically traversing the altered luminal anatomy, (2) cannulating the biliary orifice from an altered position, and (3) performing biliary interventions with available ERCP instruments. This article addresses the most common and most challenging variations in anatomy encountered by a gastroenterologist performing ERCP. It also highlights the innovations and progress that have been made in coping with these anatomic variations, with special attention paid to altered anatomy from bariatric surgery.
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Affiliation(s)
- Alexander Lee
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA 94143, USA
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Maple JT. Preparation for ERCP. ERCP 2013:73-79.e2. [DOI: 10.1016/b978-1-4557-2367-6.00009-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Laparoscopic Transgastric Endoscopy after Roux-en-Y Gastric Bypass: Case Series and Review of the Literature. Am Surg 2012. [DOI: 10.1177/000313481207801037] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic access to the gastric remnant and pancreatobiliary tree is technically difficult after Roux-en-Y gastric bypass even when facilitated by the use of specialized techniques such as balloon enteroscopy and the use of overtubes. Furthermore, such techniques are not universally available at all medical centers. We describe a case series of 13 patients with a history of Roux-en-Y gastric bypass for the treatment of morbid obesity who underwent laparoscopic transgastric endoscopy through the gastric remnant to access the duodenum or biliary tree. Charts of these patients were reviewed for demographics, indications for procedure, length of stay, morbidity, and mortality. Four of the patients had failed prior attempts to access the excluded anatomy through traditional transoral endoscopy. Two patients underwent transgastric endoscopy for evaluation of gastrointestinal bleeding. Of the 11 patients for whom endoscopic retrograde cholangiopancreatography was planned, all underwent successful biliary cannulation and sphincterotomy. There were no conversions to an open procedure or complications during the follow-up period. Laparoscopic transgastric endoscopy is a safe and reliable method to access the excluded stomach and biliary tree in patients with a history of Roux-en-Y gastric bypass.
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Currò G, Centorrino T, Low V, Navarra G. Plasma insulin and glucose time courses after biliary pancreatic diversion in morbidly obese patients with and without diabetes. Am J Surg 2012; 204:180-6. [PMID: 22481065 DOI: 10.1016/j.amjsurg.2011.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 09/21/2011] [Accepted: 09/21/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND The exact mechanism for the dramatic effect of surgical procedures for obesity on type 2 diabetes remains unknown. METHODS Five diabetic morbidly obese patients and 5 nondiabetic morbidly obese patients undergoing biliopancreatic diversion were compared retrospectively. A 75-g trans-gastrostomy glucose tolerance test was administered on the fifth day postoperatively and a standard 75-g oral glucose tolerance test was performed on the seventh day postoperatively, with blood sampling for measuring plasma glucose and insulin levels at 0, 30, 60, 90, 120, and 180 minutes. RESULTS All 5 diabetic patients were shown, at the same time, still to have diabetes or an impaired glucose tolerance test when tested through the biliopancreatic limb but patients were normal when tested through the new alimentary channel. No significant difference was seen in the nondiabetic patients. CONCLUSIONS Biliopancreatic diversion can completely normalize the glycemic cycle in type 2 diabetes patients in the week after the intervention, even before any significant weight loss has occurred. The surgical procedure itself, designed to exclude most of the stomach, duodenum, and part of the jejunum, directly affects carbohydrate homeostasis.
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Affiliation(s)
- Giuseppe Currò
- Department of Human Pathology, University of Messina, Via C. Valeria, 98100 Messina, Italy.
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Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 2012; 16:203-8. [PMID: 22042568 DOI: 10.1007/s11605-011-1760-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 10/13/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior Roux-en-Y gastric bypass (RYGB) surgery is challenging. Despite advancements in endoscopic technology, reaching the duodenum and entering the bile duct is still difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach. OBJECTIVES The objective of this study is to evaluate the success rates and complications in patients with prior RYGB anatomy who underwent LAERCP in a tertiary care center. PATIENTS Consecutive patients undergoing LAERCP between 2005 and 2010 were used for this study. OUTCOMES Biliary/pancreatic cannulation, endoscopic/laparoscopic interventions, postprocedure complications, postprocedure hospital stay, and procedure time were observed in this study. RESULTS Fifteen patients with post-RYGB surgery underwent LAERCP. Endoscopic antegrade access to the papilla was achieved through the gastric remnant in all. Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. Therapeutic interventions included biliary sphincterotomy in 14 and pancreatic sphincterotomy in two patients. There were no postoperative complications related to the endoscopic portion of the procedure. The mean duration of the procedure and the median postprocedure hospital stay were 45 min and 2 days, respectively. CONCLUSION Laparoscopic assisted ERC is a useful approach in the diagnosis and treatment of pancreaticobiliary conditions in patients with RYGB.
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Saleem A, Levy MJ, Petersen BT, Que FG, Baron TH. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 2012. [PMID: 22042568 DOI: 10.1007/s11605-011.1760-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior Roux-en-Y gastric bypass (RYGB) surgery is challenging. Despite advancements in endoscopic technology, reaching the duodenum and entering the bile duct is still difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach. OBJECTIVES The objective of this study is to evaluate the success rates and complications in patients with prior RYGB anatomy who underwent LAERCP in a tertiary care center. PATIENTS Consecutive patients undergoing LAERCP between 2005 and 2010 were used for this study. OUTCOMES Biliary/pancreatic cannulation, endoscopic/laparoscopic interventions, postprocedure complications, postprocedure hospital stay, and procedure time were observed in this study. RESULTS Fifteen patients with post-RYGB surgery underwent LAERCP. Endoscopic antegrade access to the papilla was achieved through the gastric remnant in all. Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. Therapeutic interventions included biliary sphincterotomy in 14 and pancreatic sphincterotomy in two patients. There were no postoperative complications related to the endoscopic portion of the procedure. The mean duration of the procedure and the median postprocedure hospital stay were 45 min and 2 days, respectively. CONCLUSION Laparoscopic assisted ERC is a useful approach in the diagnosis and treatment of pancreaticobiliary conditions in patients with RYGB.
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Affiliation(s)
- Atif Saleem
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street, SW, Charlton 8A, Rochester, MN 55905, USA
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