Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using a standardized protocol (with video).

Pérez-Cuadrado-Robles, Enrique;Alric, Hadrien;Quénéhervé, Lucille;Monino, Laurent;Rahmi, Gabriel;et.al.
(2023) Digestive Endoscopy — Vol. 35, n° 7, p. 909-917 (2023)

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  • Pérez-Cuadrado-Robles, Enriqueorcid-logo
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  • Alric, Hadrien
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  • Quénéhervé, Lucilleorcid-logo
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  • Monino, Laurentorcid-logoUCLouvain
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  • Rahmi, Gabriel
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Abstract
OBJECTIVES: Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP. METHODS: Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed. RESULTS: Forty-five ERCPs were performed in 31 patients (57.4 ± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n = 28, 90.3%) for biliary stones (n = 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n = 24, 77.4%) and mainly in the middle-excluded stomach (n = 21, 67.7%) with an oblique axis (n = 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n = 8), anastomotic dilation (n = 8), or failure to pass (n = 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P = 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P = 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P = 0.465). CONCLUSIONS: The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.
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Pérez-Cuadrado-Robles, E., Alric, H., Quénéhervé, L., Monino, L., Poghosyan, T., Benosman, H., Vienne, A., Perrod, G., Rebibo, L., Aidibi, A., Tenorio-González, E., Ragot, E., Karoui, M., Cellier, C., & Rahmi, G. (2023). Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using a standardized protocol (with video). Digestive Endoscopy, 35(7), 909-917. https://doi.org/10.1111/den.14544 (Original work published 2023)