Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass

Understanding the Role of Different ERCP Techniques in Post-Roux-en-Y Gastric Bypass Patients: a Systematic Review and Meta-analysis

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.

Endoscopic Management of Biliary and Pancreatic Pathologies in Roux-en-Y Gastric Bypass Patients: Development of a Treatment Algorithm Based on 9-Year Experience

BACKGROUND

Management of biliopancreatic pathology in Roux-en-Y gastric bypass (RYGB) patients is challenging despite the availability of multiple approaches like single-balloon enteroscopy-assisted ERCP (SBE-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and EUS-directed transgastric intervention (EDGI). We evaluated the outcomes of the interchangeable combination of endoscopic procedures to treat biliopancreatic pathology in RYGB patients.

MATERIALS AND METHODS

This is a monocentric retrospective study of consecutive RYGB patients with biliopancreatic pathology between June 2014 and September 2023. Primary endpoints were technical success, adverse events (AE), and parameters of endoscopic procedures according to etiology. A clinically useful management algorithm was developed.

RESULTS

A total of 102 patients with RYGB (73 women; mean age 55 ± 10 years) were included. A total of 113 SBE-ERCP (in 90 patients), 26 EDGI (in 23 patients), and 2 LA-ERCP (in 2 patients) were performed. Technical success of SBE-ERCP was lower compared to EDGI (74.4% vs 95.1%, p = 0.002). The AE rate was lower using SBE-ERCP compared to EDGI (12.4% vs 38.5%, p = 0.003). Two sub-groups based on etiology were identified as "common bile duct stone" (CBDS) and "Other." In the CBDS group, the mean number and time of procedures were lower in SBE-ERCP as the first-line technique compared to first-line EDGI (1.1 vs 2.7, p < 0.00 and 91 ± 20.7 min vs 161 ± 61.3 min, p < 0.00).

CONCLUSION

A combination of endoscopic procedures can achieve high technical success in managing biliopancreatic pathology in RYGB patients with an acceptable AE rate. In the case of CBDS, SBE-ERCP appeared to be a good first-line single-step option. For other indications, EDGI should be proposed as the first line.

Total pancreatectomy, splenectomy and remnant gastrectomy for invasive intraductal papillary mucinous neoplasm (IPMN) after prior Roux-en-Y gastric bypass

A female patient in her 50s presented with abdominal pain, nausea and jaundice. She had a history of prior Roux-en-Y gastric bypass and her body mass index was 52.5 kg/m2 Biochemical testing revealed a total bilirubin level of 14.3 mg/dL (normal<1.2 mg/dL) and carbohydrate antigen 19-9 of 38.3 units/mL (normal<36.0 units/mL). CT demonstrated a 3.2 cm pancreatic head mass, biliary and pancreatic duct dilation and cystic replacement of the pancreas. The findings were consistent with a diagnosis of mixed-type intraductal papillary mucinous neoplasm (IPMN) with invasive malignancy. The patient's Roux-en-Y anatomy precluded endoscopic biopsy, and she underwent upfront resection with diagnostic laparoscopy, open total pancreatectomy, splenectomy and remnant gastrectomy with reconstruction. Pathology confirmed T2N1 pancreatic adenocarcinoma, 1/29 lymph nodes positive and diffuse IPMN. She completed adjuvant chemotherapy. IPMNs have malignant potential and upfront surgical resection should be considered without biopsy in the appropriate clinical setting.

Italian Survey on Endoscopic Biliary Drainage Approach in Patients with Surgically Altered Anatomy

Background and Objectives: Biliary drainage (BD) in patients with surgically altered anatomy (SAA) could be obtained endoscopically with different techniques or with a percutaneous approach. Every endoscopic technique could be challenging and not clearly superior over another. The aim of this survey is to explore which is the standard BD approach in patients with SAA. Materials and Methods: A 34-question online survey was sent to different Italian tertiary and non-tertiary endoscopic centers performing interventional biliopancreatic endoscopy. The core of the survey was focused on the first-line and alternative BD approaches to SAA patients with benign or malignant obstruction. Results: Out of 70 centers, 39 answered the survey (response rate: 56%). Only 48.7% of them declared themselves to be reference centers for endoscopic BD in SAA. The total number of procedures performed per year is usually low, especially in non-tertiary centers; however, they have a low tendency to refer to more experienced centers. In the case of Billroth-II reconstruction, the majority of centers declared that they use a duodenoscope or forward-viewing scope in both benign and malignant diseases as a first approach. However, in the case of failure, the BD approach becomes extremely heterogeneous among centers without any technique prevailing over the others. Interestingly, in the case of Roux-en-Y, a significant proportion of centers declared that they choose the percutaneous approach in both benign (35.1%) and malignant obstruction (32.4%) as a first option. In the case of a previous failed attempt at BD in Roux-en-Y, the subsequent most used approach is the EUS-guided intervention in both benign and malignant indications. Conclusions: This survey shows that the endoscopic BD approach is extremely heterogeneous, especially in patients with Roux-en-Y reconstruction or after ERCP failure in Billroth-II reconstruction. Percutaneous BD is still taken into account by a significant proportion of centers in the case of Roux-en-Y anatomy. The total number of endoscopic BD procedures performed in non-tertiary centers is usually low, but this result does not correspond to an adequate rate of referral to more experienced centers.

Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size?

OBJECTIVES

The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones.

METHODS

We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105 years, mean 79.1 years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram.

RESULTS

The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5 mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success.

CONCLUSIONS

PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate.

KEY POINTS

• PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5 mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.

Safety and efficacy of LA-ERCP procedure following Roux-en-Y gastric bypass: a systematic review and meta-analysis

INTRODUCTION

Rapid weight loss following Roux-en-Y gastric bypass surgery (RYGB) translates to an increased need for endoscopic retrograde cholangiopancreatography (ERCP) intervention. Laparoscopically Assisted Transgastric ERCP (LA-ERCP) has emerged to address the issue of accessing the excluded stomach. This study aims to evaluate the safety and efficacy of LA-ERCP procedure following RYGB.

METHODS

The Cochrane, EMBASE, SCOPUS, MEDLINE, Daily and Epub databases were searched from inception to May 2022 using the PRISMA guidelines. Eligible studies reported participants older than 18 years who underwent the LA-ERCP procedure, following RYGB, and outcomes of patients.

RESULTS

27 unique studies met the inclusion criteria with 1283 patients undergoing 1303 LA-ERCP procedures. 81.9% of the patients were female and the mean age was 52.18 ± 13.38 years. The rate of concurrent cholecystectomy was 33.6%. 90.9% of procedures were undertaken for a biliary indication. The mean time between RYGB and LA-ERCP was 89.19 months. The most common intervention performed during the LA-ERCP was a sphincterotomy (94.3%). Mean total operative time was 130.48 min. Mean hospital length of stay was 2.697 days. Technical success was 95.3%, while clinical success was 93.8%. 294 complications were recorded with a 20.6% complication rate. The most frequent complications encountered were pancreatitis (6.8%), infection (6.1%), bleeding (3.4%), and perforation (2.5%). Rate of conversion to open laparotomy was 7%.

CONCLUSION

This meta-analysis presents preliminary evidence to suggest the safety and efficacy of LA-ERCP procedure following RYGB. Further investigations are warranted to evaluate the long-term efficacy of this procedure using studies with long-term patient follow-up.

Initial United Kingdom experience of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography

BACKGROUNDS/AIMS

Gallstone disease is a recognized complication of bariatric surgery. Subsequent management of choledocholithiasis may be challenging due to altered anatomy which may include Roux-en-Y gastric bypass (RYGB). We conducted a retrospective service evaluation study to assess the safety and efficacy of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in patients with RYGB anatomy.

METHODS

All the patients who underwent EDGE for endoscopic retrograde cholangiopancreatography after RYGB at two tertiary care centers in the United Kingdom between January 2020 and October 2021 were included in the study. Clinical and demographic details were recorded for all patients. The primary outcome measures were technical and clinical success. Adverse events were recorded. Hot Axios lumen apposing metal stents measuring 20 mm in diameter and 10 mm in length were used in all the patients for creation of a gastro-gastric or gastro-jejunal fistula.

RESULTS

A total of 14 patients underwent EDGE during the study period. The majority of the patients were female (85.7%) and the mean age of patients was 65.8 ± 9.8 years. Technical success was achieved in all but one patient at the first attempt (92.8%) and clinical success was achieved in 100% of the patients. Complications arose in 3 patients with 1 patient experiencing persistent fistula and weight gain.

CONCLUSIONS

In patients with RYGB anatomy, EDGE facilitated biliary access has a high rate of clinical success with an acceptable safety profile. Adverse events are uncommon and can be managed endoscopically.

Hill C, Callahan DS. Complications rate of surgically assisted endoscopic retrograde cholangiopancreatography

Background

With the rise in obesity and gastric bypass procedures, the normal anatomy and approach for endoscopic retrograde cholangiopancreatography (ERCP) is eliminated. Surgically assisted ERCP is the standard technique to access the biliary system and perform ERCP in these patients. These patients are at increased risk for cholelithiasis. As such, the need for surgically assisted ERCP has increased in patients when transoral access to the biliary tree is not possible. To date, there are little data reporting complications and outcomes of this procedure. We aimed to perform a retrospective cohort study to identify demographic, clinical and outcomes data to ascertain significant complications and complications rates of surgically assisted ERCP.

Materials and Methods

We conducted a retrospective review of electronic health record data of patients who underwent surgically assisted ERCP at three hospitals over a 10-year period, between April 2010 and July 2020, and identified 53 patient encounters for 50 unique patients.

Results

Fifty patients who underwent 53 surgically assisted ERCP were identified during the study period. Twenty-two (41.5%) of those patients had a complication. Conversion from laparoscopic to open procedure occurred in 10 cases. The overall complication rate was 44% with most complications (91%) related to surgical access as opposed to ERCP (9%).

Conclusions

Surgically assisted ERCP is associated with significant risks for complications primarily due to surgical access. Further studies need to be conducted to compare the risks of surgically assisted ERCP to other approaches for biliary access in the post-bariatric surgery population.

Biliopancreatic Endoscopy in Altered Anatomy

Background and Objectives: Anatomical post-surgical alterations of the upper gastrointestinal (GI) tract have always been challenging for performing diagnostic and therapeutic endoscopy, especially when biliopancreatic diseases are involved. Esophagectomy, gastrectomy with various reconstructions and pancreaticoduodenectomy are among the most common surgeries causing upper GI tract alterations. Technological improvements and new methods have increased the endoscopic success rate in these patients, and the literature has been rapidly increasing over the past few years. The aim of this systematic review is to identify evidence on the available biliopancreatic endoscopic techniques performed in the altered post-surgical anatomy of upper GI tract. Materials and Methods: We performed a systematic search of PubMed, MEDLINE, Cochrane Library, and SCOPUS databases. Study-level variables extracted were the last name of the first author, publication year, study design, number of patients, type of post-surgical anatomical alteration, endoscopic technique, success rate and endoscopic-related adverse events. Results: Our primary search identified 221 titles, which was expanded with studies after the citation search. The final full-text review process identified 52 articles (31 retrospective studies, 8 prospective studies and 13 case reports). We found several different techniques developed over the years for biliopancreatic diseases in altered anatomy, in order to perform both endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). They included enteroscopy-assisted ERCP (double and single balloon enteroscopy-ERCP, spiral enteroscopy-ERCP) laparoscopic assisted ERCP, EUS-Directed transgastric ERCP, EUS-directed transgastric intervention, gastric access temporary for endoscopy, and percutaneous assisted trans prosthetic endoscopic therapy. The success rate was high (most of the techniques showed a success rate over 90%) and a low rate of adverse events were reported. Conclusions: We suggest the considerationof the novel techniques when approaching patients with altered anatomy who require biliopancreatic endoscopy, focusing on the surgery type, success rate and adverse events reported in the literature.

Long Term Outcomes after Laparoscopic Assisted Trans-Gastric Endoscopic Retrograde Cholangiopancreatography

Background:

The gastric bypass is a commonly performed bariatric procedure. The stomach is divided into a small pouch as well as leaving a larger remnant that is bypassed by the gastrojejunal anastomosis. This makes access to the biliary system difficult as an endoscope cannot transverse the esophagus, roux limb, and biliopancreatic limb. Therefore, a transgastric approach (endoscopic retrograde cholangiopancreatography [t-ERCP]) through the abdominal wall and remnant stomach is necessary. This involves the surgical team providing access to the remnant stomach for the gastroenterologist to perform the t-ERCP. We have performed a number of these for biliary pathology that ranges from cancer to retained gallstones. We evaluated these patients with at least a 3-year follow-up to determine long term outcomes.

Methods:

We conducted a chart review of patients who underwent a t-ERCP with at least a 3-year follow-up. We collected de-identified data including demographics, operative details, complications, and postoperative courses.

Results:

There were 12 patients who underwent t-ERCP. Eleven patients had at least a 3-year follow-up with a mean follow-up of 68.1 months (excluding one death from pancreatic cancer). The most common pathology was benign biliary stricture (n = 6), followed by retained gallstones (n = 4), with one pancreatic cancer, and one normal examination. Two patients still had epigastric pain at long term follow-up after 3 years.

Conclusion:

T-ERCP is safe and efficacious with good long-term results.

Review of the Endoscopic, Surgical and Radiological Techniques of Treating Choledocholithiasis in Bariatric Roux-en-Y Gastric Bypass Patients and Proposed Management Algorithm

Choledocholithiasis in post-surgical bariatric Roux-en-Y gastric bypass patients presents a significant challenge secondary to altered anatomy. We aim to review the existing management options including either endoscopic, surgical, percutaneous or hybrid means. Current literature suggests reasonably successful cannulation rates for single- or double-balloon ERCP ranging from 50 to 70% and 63-83%, respectively. The hybrid technique of laparoscopic transgastric ERCP has gained popularity with success rates ranging from 90 to 100%. Conventional laparoscopic techniques like transcystic duct and transcholedochal bile duct exploration are still useful options (i.e. high success rates of 81-100% and 83-96%, respectively). The role of percutaneous transhepatic choledochography remains limited although it can help with rapid bile duct decompression. If feasible, treatment pathways should progress from least to more invasive options as required.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic-assisted ERCP following RYGB: a 12-year assessment of outcomes and learning curve at a high-volume pancreatobiliary center

INTRODUCTION

Treatment of pancreaticobiliary pathology following Roux-en-Y gastric bypass (RYGB) poses significant technical challenges. Laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP) can overcome those anatomical hurdles, allowing access to the papilla. Our aims were to analyze our 12-year institutional outcomes and determine the learning curve for LA-ERCP.

METHODS

A retrospective review of cases between 2007 and 2019 at a high-volume pancreatobiliary unit was performed. Logistic regression was used to identify predictors of specific outcomes. To identify the learning curve, CUSUM analyses and innovative methods for standardizing the surgeon's timelines were performed.

RESULTS

131 patients underwent LA-ERCP (median age 60, 81% females) by 17 surgeons and 10 gastroenterologists. Cannulation of the papilla was achieved in all cases. Indications were choledocholithiasis (78%), Sphincter of Oddi dysfunction/Papillary stenosis (18%), management of bile leak (2%) and stenting/biopsy of malignant strictures (2%). Median total, surgical and ERCP times were 180, 128 and 48 min, respectively, and 47% underwent concomitant cholecystectomy. Surgical site infection developed in 9.2% and post-ERCP pancreatitis in 3.8%. Logistic regression revealed multiple abdominal operations and magnitude of BMI decrease (between RYGB and LA-ERCP) to be predictive of conversion to open approach. CUSUM analysis of operative time demonstrated a learning curve at case 27 for the surgical team and case 9 for the gastroenterology team. On binary cut analysis, 3-5 cases per surgeon were needed to optimize operative metrics.

CONCLUSION

LA-ERCP is associated with high success rates and low adverse events. We identify outcome benchmarks and a learning curve for new adopters of this increasingly performed procedure.

Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass

BACKGROUND

Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB.

METHODS

This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE.

RESULTS

Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004).

CONCLUSIONS

LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.

Remnant Gastric Cancer After Roux-en-Y Gastric Bypass: Narrative Review of the Literature

BACKGROUND

The Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures for surgical weight loss. It has been shown that overweight may be associated with an increased risk of gastric cancer. However, the risk of remnant gastric cancer after RYGB has not been defined yet and the development of neoplasm in the excluded stomach remains a matter of concern.

METHODS

PubMed, EMBASE, and Web of Science databases were consulted. Articles that described the diagnosis and management of remnant gastric cancer after RYGB were considered.

RESULTS

Seventeen patients were included. The age of the patient population ranged from 38 to 71 years. The most commonly reported symptoms were abdominal pain, nausea/vomiting, and anemia. Abdominal computed tomography was used for diagnosis in the majority of patients. The neoplasm was located in the antrum/pre-pyloric region in 70% of cases and adenocarcinoma was the most common tumor histology (80%). An advanced tumor stage (III-IV) was diagnosed in almost 70% of patients and 40% were considered unresectable. Gastrectomy with lymphadenectomy was performed in 9 cases (53%). Post-operative morbidity was 12%. The follow-up ranged from 3 to 26 months and the overall disease-related mortality rate was 33.3%.

CONCLUSION

The development of remnant gastric cancer after RYGB is rare. Surgeons should be aware of this potential event and the new onset of epigastric pain, nausea, and anemia should raise clinical suspicion. Further epidemiologic studies are warranted to deeply investigate the post-RYGB-related risk of remnant gastric cancer development in high-risk populations.

Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis

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.

EDGE in Roux-en-Y gastric bypass: How does it compare to laparoscopy-assisted and balloon enteroscopy ERCP: a systematic review and meta-analysis

Background and study aims  Endoscopic ultrasound-directed transgastric ERCP (EDGE) is a new endoscopic procedure to perform ERCP in Roux-en-y gastric bypass (RYGB) patients. The aim of this study was to conduct a systematic review and meta-analysis to evaluate technical success, clinical success and adverse effects of EDGE and compare it to laparoscopic ERCP (LA-ERCP) and balloon ERCP (BE-ERCP). Patients and methods  We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, LILACS, SCOPUS, and Web of Science databases to identify studies reporting on EDGE, LA-ERCP, and BE-ERCP. The primary outcome was to evaluate technical and clinical success of all three procedures and the secondary analysis focused on calculating the pooled rate of all adverse events (AEs), along with the commonly reported AE subtypes. Results  Twenty-four studies on 1268 patients were included in our analysis with the majority of the population being males with mean age 53.72 years. Pooled rates of technical and clinical success with EDGE wer 95.5 % and 95.9 %, with LA-ERCP were 95.3 % and 92.9 % and were BE-ERCP were 71.4 % and 58.7 %, respectively. Pooled rates of all AEs with EDGE were 21.9 %, with LA-ERCP 17.4 % and with BE-ERCP 8.4 %. Stent migration was the most common AE with EDGE with 13.3 % followed by bleeding with 6.6 %. Conclusion  Our meta-analysis demonstrated that the technical and clinical success of EDGE procedure is better than BE-ERCP and comparable to that of LA-ERCP in RYGB patients. EDGE also has a similar safety profile as compared to LA-ERCP but has higher AE rate as compared to BE-ERCP.

Outcomes of laparoscopic-assisted ERCP in gastric bypass patients at a community hospital center

BACKGROUND

Obesity is a prevalent issue in today's society, increasing the number of gastric weight loss surgeries (Bowman et al. in Surg Endosc. https://doi.org/10.1007/s00464-016-4746-8 , 2016; Choi et al. in Surg Endosc. https://doi.org/10.1007/s00464-013-2850-6 , 2013; Paranandi et al. in Frontline Gastroenterol. https://doi.org/10.1136/flgastro-2015-100556 , 2015; Richardson et al. in http://www.ingentaconnect.com/content/sesc/tas , 2012). This presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ERCP) as the traditional is technically difficult, requiring a longer endoscope with a reported success rate of less than 70% (Roberts et al. in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016032/ , 2008). A solution is laparoscopic-assisted ERCP (LA-ERCP) via gastrostomy. We present our experience with LA-ERCP at our teaching community hospital in a large cohort of patients.

METHODS

An IRB-approved retrospective chart review was performed on patients with prior gastric bypass surgery who underwent LA-ERCP from April 2008 to April 2016. The procedure involved two bariatric surgeons and one gastroenterologist. The gastric remnant was secured to the abdominal wall with a purse-string suture and transfascial stay sutures. After gastrostomy creation of a duodenoscope was inserted to perform ERCP. Biliary sphincterotomy, dilation, and stone removal were performed as indicated. We observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital readmission, and bile leak.

RESULTS

Thirty-two patients met inclusion criteria. The majority of indications for LA-ERCP was choledocholithiasis (16/32). The remainder of cases included indications such as abnormal LFTs with biliary dilation (11/32), acute pancreatitis (2/32), cholangitis (2/32), and bile leak (1/32). LA-ERCP was successfully performed in all patients. Biliary sphincterotomy and stone extraction were performed on 31/32 patients. One patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. One patient developed acute pancreatitis with elevated pancreatic enzymes which resolved on POD2. The median length of stay was 2 days.

CONCLUSION

LA-ERCP is a safe and feasible alternative to open surgery and can be safely implemented at community hospitals with adequately trained providers. Our large study proves that in this minimally invasive era, LA-ERCP provides gastric bypass patients a safe alternative with less pain and increased satisfaction.

Trans-Gastric ERCP After Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis

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.

Laparoscopic Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Results at 5-Year Follow-up

BACKGROUND

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard treatment for morbid obesity. After LRYGB, the endoscopic access to the gastric remnant and pancreaticobiliary system is challenging. The laparoscopic gastric bypass with fundectomy and exploration of the gastric remnant (LRYGBfse) was introduced in an attempt to overcome this limitation. The purpose of this study was to analyze the medium-term outcomes and safety of LRYGBfse.

METHODS

Observational prospective single-arm multicenter cohort study. Patients with BMI > 35 kg/m² were included. Previous open abdominal surgery was an exclusion criterion. Postoperative 1, 2, 3, and 5-year weight loss, BMI decrease, and percentage of excess weight loss (%EWL) were recorded. Wilcoxon signed rank sum test was used for paired data.

RESULTS

Among 653 enrolled patients, 229 completed the 5-year follow-up. Preoperative median body weight (kg) and BMI (kg/m²) were 133.4 kg (interquartile range (IQR) = 12.0) and 48.2 kg/m² (IQR = 10.1), respectively. Median 5-year body weight, BMI, and %EWL were 83.7 (IQR = 17.3), 31.2 (IQR = 7.7), and 74.8 (IQR = 23.4), respectively, all significantly improved compared to baseline (p = 0.002, p = 0.001, and p = 0.012, respectively). Comorbid improvement or resolution was observed in 88% of the patients. No major intraoperative complications were reported. Postoperative overall morbidity and mortality rates were 1 and 0%, respectively. Banding removal was necessary in one patient 62 months after the index operation.

CONCLUSIONS

The LRYGBfse seems safe and effective with durable results at 5-year follow-up. Endoscopic exploration of the gastric remnant is an additional valuable tool.

Overall outcomes of laparoscopic-assisted ERCP after Roux-en-Y gastric bypass and sphincter of Oddi dysfunction subgroup analysis

Background and study aims  Biliary access following Roux-en-Y gastric bypass (RYGB) anatomy presents a significant challenge. Long-term outcomes of laparoscopic-assisted trans-gastric ERCP (LA-ERCP) including sphincter of Oddi dysfunction (SOD) subtypes have not been thoroughly examined. Our study aims to present our overall outcomes of trans-gastric LAERCP and examine a significant subgroup of patients with SOD after RYGB. Patients and methods  A retrospective review of RYGB patients who underwent LA-ERCP between 2009 and 2016 identified 51 patients. A subgroup of 22 patients with SOD were examined and contacted by phone survey to determine long-term symptom resolution. Results  Post-procedure length of stay was 1.9 days (SD 3.0). There was one conversion from laparoscopic to open procedure. Selective cannulation rate was 100 %. Mean follow-up was 14.6 months. There were two major operative complications, two major ERCP-related complications, and five wound infections (9.8 %). No deaths or episodes of pancreatitis occurred. Seventeen patients had biliary SOD (Type I = 9, Type II = 8). The remaining four had pancreatic SOD (Type I = 1, Type II = 4). SOD subgroup follow-up was 21.4 months (SD 18.1). All patients with Type I biliary and 75 % with Type I pancreatic SOD reported complete resolution of their symptoms. Conclusions  Consistent with other published series, LA-ERCP yields excellent cannulation rates after RYGB. Successful treatment of pancreatic and Type 1 biliary SOD suggests that there is significant symptomatic benefit to treating this patient population. However, an overall complication rate of approximately 15 % with LAERCP leaves open the possibility for improvements in access techniques in post-RYGB patients.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP): ANALYSIS OF THE EFFECTIVENESS AND SAFETY OF THE PROCEDURE IN THE PATIENT WITH ROUX-EN-Y GASTRIC BYPASS

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.

EUS-guided hepaticoenterostomy as a portal to allow definitive antegrade treatment of benign biliary diseases in patients with surgically altered anatomy

BACKGROUND AND AIMS

EUS-guided hepaticoenterostomy (EUS-HE) usually is reserved for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiography (ERC) or inaccessible biliary tree in surgically altered anatomy (SAA). We describe the outcome of EUS-HE and antegrade therapy for benign biliary disease in patients with SAA.

METHODS

Retrospective review of 20 consecutive patients with surgically altered anatomy and benign biliary obstruction who underwent EUS-HE performed by 1 endoscopist at a tertiary-care center over a 3-year period.

RESULTS

During the study period, 37 patients underwent EUS-HE; 24 for benign disease. Of these, 20 patients had SAA and were analyzed (15 women, mean age, 62 years). SAA consisted of 9 Roux-en-Y gastric bypasses, 6 Roux-en-Y hepaticojejunostomy, 2 Billroth II procedures, and 3 Whipple procedures. Indications for ERC were common bile duct stones (n = 8), benign postoperative strictures (n = 7), chronic pancreatitis (n = 3), inflammatory stricture (n = 1), and treatment of a bile leak (n = 1). Five patients had previously failed balloon enteroscopy-assisted ERCs. The approach was transgastric in 15 and transjejunal in 5. In all cases, a branch of the left hepatic duct with a mean diameter of 7.8 mm was accessed. Median stent length was 80 mm, with diameters of 8 or 10 mm. Antegrade, definitive endoscopic therapy via the HE was performed in 18 patients, with an average of 2.7 procedures performed for resolution of stones and/or downstream strictures. HE stents were removed in 17 patients after a mean of 91 days without adverse events. Three patients experienced mild adverse events (1 with postprocedural pancreatitis after placement of a 10F transpapillary stent, 1 with postprocedural abdominal pain, and 1 with postprocedural cholangitis) requiring hospitalization for fewer than 3 nights; no severe adverse events occurred. The average postprocedural hospital stay was 1.3 days. No deaths occurred during follow-up.

CONCLUSIONS

EUS-HE is safe and effective in the management of benign biliary obstruction in patients with surgically altered anatomy. It creates a portal to allow definitive, antegrade therapy and is a viable alternative to other endoscopic methods in this patient population.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMS

The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP.

METHODS

This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated.

RESULTS

A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred.

CONCLUSIONS

Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Treatment of Common Bile Duct Stones in Gastric Bypass Patients with Laparoscopic Transgastric Endoscopic Retrograde Cholangiopancreatography

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.

Percutaneous transgastric interventional radiology-operated duodenoscopy for the identification of duodenal perforation and Graham patch dehiscence

Patients with a Roux-en-Y gastric bypass may be challenging diagnostic and therapeutic dilemmas for gastroenterologists and endoscopists due to anatomic considerations. Pancreaticobiliary limb pathology is particularly difficult to diagnose from standard endoscopic approaches as it often requires double balloon enteroscopy. Percutaneous access and gastrostomy placement into the gastric remnant, however, is a commonly performed procedure by interventional radiology. This report describes the identification of duodenal perforation and Graham patch dehiscence in the pancreaticobiliary limb of a patient with a prior Roux-en-Y gastric bypass who had failed traditional endoscopic measures, using transgastric remnant interventional duodenoscopy and confirmed with methylene blue injection into a periduodenal abscess.

Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients

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.