|
1
|
Ghandour B, Keane MG, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Sharaiha RZ, Kowalski TE, Khashab MA, Shrigiriwar A, Zhang L, Mony S, Khan A, Loren DE, Chiang A, Schlachterman A, Kumar A, Saab O, Blake B, Obri MS. Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study. Gastrointest Endosc 2023; 97:260-267. [PMID: 36228699 DOI: 10.1016/j.gie.2022.09.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. METHODS This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). CONCLUSIONS Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.
Collapse
Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
2
|
Ghandour B, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Bejjani M, Sharaiha RZ, Kowalski TE, Khashab MA. EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience. Gastrointest Endosc 2022; 96:630-638. [PMID: 35623383 DOI: 10.1016/j.gie.2022.05.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. METHODS This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. RESULTS Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. CONCLUSIONS EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.
Collapse
Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | |
Collapse
|
|
3
|
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the standard treatment of biliary disease with high success rates of greater than 90% in patients with standard anatomy. However, alterations in upper gastrointestinal anatomy can significantly complicate endoscopic biliary intervention. The past decade has seen significant advances in the endoscopic management of patients with altered anatomy. This review article will provide tips and tricks for successful biliary access in the most common surgical alterations with a focus on the management of biliary diseases following Roux-en-Y (RY) reconstructions.
Collapse
Affiliation(s)
- Linda Y Zhang
- Department of Gastroenterology & Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Mouen A Khashab
- Department of Gastroenterology & Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| |
Collapse
|
|
4
|
|
|
5
|
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.
Collapse
|
|
6
|
Sawas T, Storm AC, Bazerbachi F, Fleming CJ, Vargas EJ, Chandrasekhara V, Andrews JC, Levy MJ, Martin JA, Petersen BT, Topazian MD, Abu Dayyeh BK. An innovative technique using a percutaneously placed guidewire allows for higher success rate for ERCP compared to balloon enteroscopy assistance in Roux-en-Y gastric bypass anatomy. Surg Endosc 2019; 34:806-813. [DOI: 10.1007/s00464-019-06832-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 05/14/2019] [Indexed: 12/13/2022]
|
|
7
|
Palermo M, Neto MG. Gallbladder stones in bariatrics and management of choledocholithiasis after gastric bypass. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii180035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Mariano Palermo
- Department of Bariatric Surgery, Centro CIEN – Diagnomed, Affiliated Institution to the University of Buenos Aires and DAICIM Foundation, Buenos Aires, Argentina
| | - Manoel Galvao Neto
- Department of Surgery, Florida Interntional University and Endovitta Institute, Sao Paulo, Brazil
| |
Collapse
|
|
8
|
Bukhari M, Kowalski T, Nieto J, Kunda R, Ahuja NK, Irani S, Shah A, Loren D, Brewer O, Sanaei O, Chen YI, Ngamruengphong S, Kumbhari V, Singh V, Aridi HD, Khashab MA. An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc 2018; 88:486-494. [PMID: 29730228 DOI: 10.1016/j.gie.2018.04.2356] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 04/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ERCP is challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy. EUS-guided gastrogastrostomy (GG) creation is a promising novel technique to access the excluded stomach to facilitate conventional ERCP. We aimed to compare procedural outcomes and adverse events (AEs) between EUS-guided GG-assisted ERCP (EUS-GG-ERCP) and enteroscopy-assisted ERCP (e-ERCP) in patients with RYGB. METHODS Patients with RYGB anatomy who underwent EUS-GG-ERCP or e-ERCP between 2014 and 2016 at 5 tertiary centers were included. The primary outcome was technical success of ERCP, defined as successful cannulation of the selected duct with successful intervention as intended. Secondary outcomes included total procedural time (in the EUS-GG group, total procedural time included EUS-GG creation plus ERCP procedure time), length of hospital stay, and rate/severity of AEs graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS A total of 60 patients (mean age, 57.2 ± 13.2; 75% women) were included, of whom 30 (50%) underwent EUS-GG-ERCP and 30 (50%) underwent e-ERCP (double-balloon enteroscope ERCP, 19; single-balloon enteroscope ERCP, 11). The technical success rate was significantly higher in the EUS-GG-ERCP versus the e-ERCP group (100% vs 60.0%, P < .001). Total procedure time was significantly shorter in patients who underwent EUS-GG-ERCP (49.8 minutes vs 90.7 minutes, P < .001). Postprocedure median length of hospitalization was shorter in the EUS-GG group (1 vs 10.5 days, P = .02). Rate of AEs was similar in both groups (10% vs 6.7%, P = 1). CONCLUSIONS EUS-GG-ERCP may be superior to e-ERCP in patients with RYGB anatomy in terms of a higher technical success and shorter procedural times and offers a similar safety profile.
Collapse
Affiliation(s)
- Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA; Division of Medicine and Gastroenterology and Hepatology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jose Nieto
- Borland-Groover Clinic, Jacksonville, Florida, USA
| | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Apeksha Shah
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Loren
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Hanaa Dakour Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
|
9
|
Shaikh SH, Stenz JJ, McVinnie DW, Morrison JJ, Getzen T, Carlin AM, Mir FR. Percutaneous gastric remnant gastrostomy following Roux-en-Y gastric bypass surgery: a single tertiary center's 13-year experience. Abdom Radiol (NY) 2018; 43:1464-1471. [PMID: 28929218 DOI: 10.1007/s00261-017-1313-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of the study is to evaluate the indications, techniques, and outcomes for percutaneous gastrostomy placement in the gastric remnant following Roux-en-Y gastric bypass (RYGB) in bariatric patients. MATERIALS AND METHODS Retrospective chart review and summary statistical analysis was performed on all RYGB patients that underwent attempted percutaneous remnant gastrostomy placement at our institution between April 2003 and November 2016. RESULTS A total of 38 patients post-RYGB who underwent gastric remnant gastrostomy placement were identified, 32 women and 6 men, in which a total of 41 procedures were attempted. Technical success was achieved in 39 of the 41 cases (95%). Indications for the procedure were delayed gastric remnant emptying/biliopancreatic limb obstruction (n = 8), malnutrition related to RYGB (n = 17), nutritional support for conditions unrelated to RYGB (n = 15), and access for endoscopic retrograde cholangiopancreatography (ERCP, n = 1). Insufflation of the gastric remnant was performed via a clear window (n = 35), transhepatic (n = 5), and transjejunal (n = 1) routes. Five complications were encountered. The four major complications (9.8%) included early tube dislodgement with peritonitis, early tube dislodgement requiring repeat intervention, intractable pain, and upper gastrointestinal bleeding. A single minor complication occurred (2.4%), cellulitis. CONCLUSION Patients with a history of RYGB present a technical challenge for excluded gastric remnant gastrostomy placement. As the RYGB population increases and ages, obtaining and maintaining access to the gastric remnant is likely to become an important part of interventional radiology's role in the management of the bariatric patient.
Collapse
|
|
10
|
Banerjee N, Parepally M, Byrne TK, Pullatt RC, Coté GA, Elmunzer BJ. Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2017; 13:1236-1242. [PMID: 28336200 DOI: 10.1016/j.soard.2017.02.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/20/2017] [Accepted: 02/06/2017] [Indexed: 12/28/2022]
Abstract
Balloon-assisted endoscopic retrograde cholangiopancreatoscopy (ERCP) in Roux-en-Y gastric bypass (RYGB) patients is technically challenging due to anatomic and accessory constraints, thus success rates are modest. Transgastric ERCP (TG-ERCP) offers a viable alternative. We aimed to systematically review the literature on TG-ERCP in RYGB patients to better define the technical approaches, success rates, and adverse events of this procedure. A computer-assisted search of the Embase and PubMed databases was performed to identify studies that focused on the techniques and clinical outcomes of TG-ERCP. Two investigators independently identified studies and abstracted relevant data. The literature search yielded 26 eligible studies comprising 509 TG-ERCP cases. Access to the excluded stomach to facilitate ERCP was achieved laparoscopically in 58% of reported cases, via open surgery (6% of reported cases), by antecedent placement of a percutaneous gastrostomy tube (33%), or with endoscopic ultrasound assistance (3%). Successful gastric access was reported in 100% of cases and successful ductal cannulation in 98.5%. Adverse events were reported in 14% of cases; 80% of these were related to gastrostomy creation and the rest were attributable to ERCP. Wound infections (n = 19, 3.7%) were the most common gastrostomy-related adverse event, and post-ERCP pancreatitis (n = 7, 1.4%) was the most common ERCP-related adverse event. No deaths were reported. Based on existing observational studies, TG-ERCP appears to be a safe and highly effective approach in patients with RYGB anatomy. Additional research and clinical experience are needed to more precisely define the risk-benefit ratio and optimal technique of TG-ERCP.
Collapse
Affiliation(s)
- Nikhil Banerjee
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Mayur Parepally
- Division of Gastroenterology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - T Karl Byrne
- Division of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Rana C Pullatt
- Division of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
|
11
|
Goyal D, Kasapoglu B, Thosani N. Endoscopic retrograde cholangiopancreatography in surgically altered anatomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170009] [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: 11/22/2022] Open
Affiliation(s)
- Deepinder Goyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Benan Kasapoglu
- Department of Gastroenterology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, McGovern Medical School, UTHealth, Houston, TX, USA
| |
Collapse
|
|
12
|
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]
|
|
13
|
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.
Collapse
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
| |
Collapse
|
|
14
|
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]
|
|
15
|
Acute pancreatitis in patients after bariatric surgery: incidence, outcomes, and risk factors. Obes Surg 2015; 24:2025-30. [PMID: 24972683 DOI: 10.1007/s11695-014-1337-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The incidence of acute pancreatitis (AP) in bariatric surgery patients is not known. Ouraim was to determine the incidence, outcomes, and risk factors of AP in post-bariatric surgery patients. METHODS An historical cohort study was conducted of all patients who underwent Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric banding, and revisional procedures at our institution from January 2004 to September 2011. Patients who developed AP were identified by review of the electronic medical record. A nested case-control study using Cox regression analysis was done to identify risk factors. RESULTS A total of 2695 patients underwent bariatric surgery. Twenty-eight patients (1.04 %) developed AP during a median follow-up of 3.5 years (interquartile range [IQR] 1.9-5.8). One patient had severe AP, and there was one AP-related death. In the case-control study, the only baseline variable that predicted post-operative AP was a prior history of AP. Three other variables identified after surgery were associated with AP: (1) rapid weight loss as measured by percent of excess weight loss (EWL) at the first post-operative visit, (2) abnormal findings on post-operative ultrasound (stones, sludge or ductal dilation), and (3) post-operative complications of bowel leak or anastomotic stricture. CONCLUSIONS The incidence of AP in this cohort is 1.04 %, which is higher than that reported for the general population (~17/100,000, 0.017 %). Most cases were clinically mild and managed conservatively with good outcomes. Rapid post-operative weight loss and the presence of gallstones or sludge on post-operative ultrasound were significant risk factors for AP.
Collapse
|
|
16
|
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.
Collapse
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
| | | | | | | | | | | | | |
Collapse
|
|
17
|
Abstract
ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates.
Collapse
|
|
18
|
Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Pasha SF, Saltzman JR, Shaukat A, Wang A, Stefanidis D, Richardson WS, Kothari SN, Cash BD. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 2015; 81:1063-1072. [PMID: 25733126 DOI: 10.1016/j.gie.2014.09.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/11/2014] [Indexed: 12/22/2022]
|
|
19
|
Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Pasha SF, Saltzman JR, Shaukat A, Wang A, Stefanidis D, Richardson WS, Khothari SN, Cash BD. The role of endoscopy in the bariatric surgery patient. Surg Obes Relat Dis 2015; 11:507-517. [PMID: 26093766 DOI: 10.1016/j.soard.2015.02.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
|
20
|
ASGE STANDARDS OF PRACTICE COMMITTEE. The role of endoscopy in the bariatric surgery patient. Surg Endosc 2015; 29:1007-1017. [PMID: 26038784 DOI: 10.1007/s00464-015-4111-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
|
21
|
Kahaleh M, Artifon ELA, Perez-Miranda M, Gaidhane M, Rondon C, Itoi T, Giovannini M. Endoscopic ultrasonography guided drainage: summary of consortium meeting, May 21, 2012, San Diego, California. World J Gastroenterol 2015; 21:726-41. [PMID: 25624708 PMCID: PMC4299327 DOI: 10.3748/wjg.v21.i3.726] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/29/2014] [Accepted: 06/21/2014] [Indexed: 02/07/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred procedure for biliary and pancreatic drainage. While ERCP is successful in about 95% of cases, a small subset of cases are unsuccessful due to altered anatomy, peri-ampullary pathology, or malignant obstruction. Endoscopic ultrasound-guided drainage is a promising technique for biliary, pancreatic and recently gallbladder decompression, which provides multiple advantages over percutaneous or surgical biliary drainage. Multiple retrospective and some prospective studies have shown endoscopic ultrasound-guided drainage to be safe and effective. Based on the currently reported literature, regardless of the approach, the cumulative success rate is 84%-93% with an overall complication rate of 16%-35%. endoscopic ultrasound-guided drainage seems a viable therapeutic modality for failed conventional drainage when performed by highly skilled advanced endoscopists at tertiary centers with expertise in both echo-endoscopy and therapeutic endoscopy.
Collapse
|
|
22
|
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.
Collapse
|
|
23
|
Abstract
Endoscopic retrogade cholangiopancreatography (ERCP) is a standard of care endoscopic technique using a conventional side-viewing duodenoscope to treat a wide variety of biliopancreatic pathologies. However, surgically altered gastric and/or small bowel anatomy renders ERCP more challenging because of several reasons. Depending on the type of surgical reconstruction, different endoscopic approaches have been developed in order to perform therapeutic ERCP. The current review highlights the latest ERCP developments to deal with biliopancreatic problems in patients with surgically altered anatomy, and discusses future directions of improvement.
Collapse
Affiliation(s)
- Tom G Moreels
- Department of Gastroenterology & Hepatology, Antwerp University Hospital, Wilrijkstraat 10, 2650 Antwerp, Belgium.
| |
Collapse
|
|
24
|
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.
Collapse
|
|
25
|
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.
Collapse
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
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
26
|
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.
Collapse
Affiliation(s)
- Alexander Lee
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA 94143, USA
| | | |
Collapse
|
|
27
|
Martel G, Abaskharoun R, Ryan SE, Mamazza J, Fairfull-Smith RJ, Balaa FK, Mimeault R. Technique for salvage ERCP with gastric bypass anatomy and severe intra-abdominal adhesions. J Laparoendosc Adv Surg Tech A 2013; 23:263-6. [PMID: 23317409 DOI: 10.1089/lap.2012.0346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Choledocholithiasis is a complex problem in patients with Roux-en-Y gastric bypass anatomy. Several techniques of biliary clearance have been described, but these can be limited by intra-abdominal adhesions. PATIENT AND METHODS A 36-French surgical gastrostomy was created and was allowed to mature for 10 weeks. It was exchanged for a 15-mm laparoscopic surgery trocar under fluoroscopic guidance. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out using the trocar as a stable access point. Complete biliary clearance was achieved in one sitting using sphincterotomy, large-diameter biliary orifice balloon dilation, and balloon/basket sweeps. RESULTS Total endoscopy time was 120 minutes. There were no complications associated with the procedure. The postprocedure length of stay was 2 days. The total bilirubin level at discharge was 1.2 mg/dL (20 μmol/L). CONCLUSIONS In patients with gastric bypass anatomy and severe adhesions, successful salvage therapeutic ERCP can be achieved using a gastrostomy tract and a large-bore laparoscopy trocar for access to the defunctioned stomach.
Collapse
Affiliation(s)
- Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
| | | | | | | | | | | | | |
Collapse
|
|
28
|
Baron TH, Song LMWK, Ferreira LEVV, Smyrk TC. Novel approach to therapeutic ERCP after long-limb Roux-en-Y gastric bypass surgery using transgastric self-expandable metal stents: experimental outcomes and first human case study (with videos). Gastrointest Endosc 2012; 75:1258-63. [PMID: 22624815 DOI: 10.1016/j.gie.2012.02.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 02/13/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND ERCP in Roux-en-Y gastric bypass (RYGB) patients is challenging. Balloon-assisted enteroscopy (BAE) allows access to the excluded stomach with creation of a percutaneous endoscopic gastrostomy (PEG). Transgastric self-expandable metal stent (SEMS) placement may allow antegrade ERCP in 1 session. OBJECTIVE To determine the feasibility of transgastric endoscopy and ERCP through a newly created PEG augmented by SEMS placement. DESIGN Prospective live animal study; human case report. SETTINGS Animal laboratory and endoscopy units, tertiary care medical center. SUBJECTS Nine domestic pigs; 1 patient. INTERVENTIONS PEG tract with SEMS placement; transgastric endoscopy through SEMS. MAIN OUTCOME MEASUREMENTS Technical success, feasibility of transgastric endoscopy. RESULTS Successful SEMS deployment was achieved in 9 of 9 animals. The stent was removed in 6 animals; 3 were killed within 24 hours (group A) and 3 were killed 1 week later (group B). In 3 animals, stents remained in place, they were killed 9 to 15 days later (group C). Duodenoscopy was difficult in 1 animal from group A resulting in stent dislodgment. Peristomal infection occurred in 1 animal in group B. In group C, 1 stent was buried subcutaneously and 1 completely migrated out. Necropsy showed no peritoneal fluid or peritonitis in any animal. In the 1 patient, BAE-assisted PEG and SEMS placement in the excluded stomach allowed antegrade ERCP and biliary sphincterotomy without adverse events. LIMITATIONS Small number of subjects. CONCLUSIONS Performance of PEG with immediate SEMS placement allows for antegrade transgastric ERCP during 1 procedure. With the use of BAE, retrograde PEG/SEMS in excluded stomach allows therapeutic ERCP without need for surgery.
Collapse
Affiliation(s)
- Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | | | |
Collapse
|
|
29
|
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.
Collapse
Affiliation(s)
- Giuseppe Currò
- Department of Human Pathology, University of Messina, Via C. Valeria, 98100 Messina, Italy.
| | | | | | | |
Collapse
|
|
30
|
Samarasena JB, Nguyen NT, Lee JG. Endoscopic retrograde cholangiopancreatography in patients with roux-en-Y anatomy. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:78-83. [PMID: 23687591 PMCID: PMC3655346 DOI: 10.4161/jig.22203] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 01/28/2012] [Accepted: 01/29/2012] [Indexed: 12/31/2022]
Affiliation(s)
- Jason B Samarasena
- Division of Gastroenterology, University of California-Irvine, Orange, California
| | | | | |
Collapse
|