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.
-
Keywords: EUS-directed transgastric ERCP; Lumen-apposing metal stent; Cholangiopancreatography, endoscopic retrograde; Gastric bypass
INTRODUCTION
The obesity epidemic, coupled with the relative failure of non-invasive weight loss reduction techniques, has led to the growth of bariatric surgery. Between 1998 and 2008, the United States witnessed a 10-fold increase in bariatric surgeries [1,2]. With a growing body of evidence expounding the value of bariatric surgery in controlling obesity and its complications [3-6], there is a growing need to develop diagnostic and therapeutic techniques that are effective for patients with the altered anatomy that results from these procedures.
Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation [7]. Patients who have undergone RYGB pose unique challenges in situations wherein endoscopic retrograde cholangiopancreatography (ERCP) is required. These difficulties include maneuvering through gastrointestinal anastomoses as well as identifying and gaining access to the ampulla of Vater and the biliary tree while approaching from a reverse direction without a side-viewing scope or other common ERCP accessories.
A number of transoral and surgical approaches have been described for ERCP in these patients. Transoral approaches include the use of standard ERCP, which has been shown to have success rates as low as 33% in patients with RYGB [8], and enteroscopy-assisted ERCP (EA-ERCP) [9], which has suboptimal success rates of 70% [10] secondary to the lack of an elevator and forward vision on the enteroscope. Surgical approaches consist of laparoscopy- or laparotomy-assisted ERCP through a gastrostomy tract (LA-ERCP) [11,12], which carries impressive technical success rates compared to EA-ERCP (95% vs. 63%), but is associated with higher complication rates (14.5% vs. 3.1%), as well as higher healthcare costs and difficulties with coordination between multiple interdisciplinary teams [13-16].
Recently, an endoscopic ultrasound (EUS)-guided procedure for ampullary access has been developed, termed internal EUS-directed transgastric ERCP (EDGE). This technique involves accessing the excluded stomach from the gastric pouch by placing a lumen-apposing metal stent (LAMS) across a fistula tract with EUS guidance, and subsequently performing conventional ERCP through the LAMS [17,18]. We present the first multicenter experience regarding the efficacy and safety of the EDGE technique.
MATERIALS AND METHODS
Study overview
All patients who underwent EDGE between March 2014 and August 2015 in two academic centers in the United States were included in a prospective registry. Demographic data, procedural information, and clinical follow-up data were documented. Technical success was defined as successful deployment of the LAMS. Clinical success was defined as successful ERCP and/or EUS through the LAMS. Adverse events related to EDGE were separated from ERCP- or EUS-related complications, and were defined as procedural or postprocedural bleeding, stent migration, perforation, and infection. All patients provided written informed consent prior to the procedure.
Procedural technique
The excluded stomach was located endosonographically with a linear echoendoscope (GF-UCT180; Olympus, Central Valley, PA, USA) from the remnant gastric pouch or the afferent limb, and then accessed with a 19-gauge EUS needle (ECHO-19; Cook Medical, Winston-Salem, NC, USA) (Fig. 1). Contrast, along with 120 cc of water, was injected through the 19-gauge needle to confirm the position within and distend the excluded stomach. A 0.035” wire (HydraJag; Boston Scientific, Natick, MA, USA) was advanced through the needle and coiled within the lumen of the excluded stomach (Fig. 2). The fistula tract was created with cautery (RX Needle Knife; Boston Scientific) and dilated with a 4 mm balloon (Hurricane RX; Boston Scientific) prior to advancement of the LAMS (Axios; Boston Scientific) delivery system into the excluded stomach. The distal flange of the stent was deployed under fluoroscopic and endosonographic guidance into the excluded stomach, while the proximal flange was deployed under endoscopic visualization into the remnant gastric pouch or afferent limb (Fig. 3). The lumen of the stent was dilated with a dilating balloon to the diameter of the stent (control radial expansion [CRE]; Boston Scientific) (Fig. 4). This allowed for antegrade passage of a duodenoscope (TGF-Q180V; Olympus) or an echoendoscope (GF-UCT180; Olympus) through the LAMS into the stomach remnant and to the ampulla, where conventional ERCP or EUS could be performed, either during the index procedure or during subsequent procedure(s) (Figs, 5, 6). Once ampullary access was no longer required, the LAMS was removed using a snare (25 mm SnareMaster; Olympus) and the defect was closed using an over-the-scope clip (OTSC; Ovesco, Los Gatos, CA, USA) and/or endoscopic suturing (Overstitch; Apollo Endosurgery, Austin, TX, USA).
RESULTS
Sixteen patients underwent EDGE (Table 1). The average age of the patients was 55.5 years (range, 7 to 82). Thirteen patients (81%) were female. Indications for the procedure included biliary stricture (n=7), choledocholithiasis (n=5), recurrent acute pancreatitis (n=3), pancreatic lesion (n=3), and cholangitis (n=1).
Technical success
Technical success was achieved in 100% of patients. Six patients (37.5%) had gastrogastric fistulas, and 10 (62.5%) had jejunogastric fistulas. All patients had a 15 mm diameter LAMS successfully placed. The average hospital stay was 2.7 days (range, 0 to 16) postprocedure.
Clinical success
ERCP and/or EUS through the LAMS was achieved in 10 patients (91%; 10 of 11 patients). Five patients were still awaiting fistula tract maturation prior to ERCP or EUS at the time of publication, four patients underwent conventional ERCP during the index procedure, six underwent ERCP at a subsequent session following fistula maturation, and one patient had an aborted ERCP due to intestinal perforation, which was managed conservatively. All patients who underwent ERCP experienced successful therapeutic intervention. The average number of ERCP sessions was 3.5. Three patients with pancreatic lesions underwent EUS-fine needle aspiration performed through the LAMS; all three procedures were performed after fistula tract maturation.
Stent removal and fistula closure
Ten patients (62.5%) underwent removal of the LAMS. Among these patients, the fistula was closed with endoscopic suturing in seven patients (70%) and with an OTSC in two patients (20%). In one patient, the fistula tract was left to close by secondary intention. Of the remaining six patients, one patient experienced a jejunal perforation during the attempt to advance the duodenoscope through the LAMS. The perforation was closed endoscopically and did not require surgery. One patient passed away from pancreatic cancer prior to LAMS removal, and in four patients, the LAMS was left in place for continued pancreaticobiliary access. Eight of the 10 patients underwent imaging to confirm fistula closure following LAMS removal; among these patients, one had a persistent leak on imaging and was scheduled to undergo repeat closure, while imaging of the remaining seven patients confirmed the absence of any remaining fistula tract. Two patients were awaiting imaging following LAMS removal. No patients required repeat pancreaticobiliary access after LAMS removal.
Adverse events
In three patients (19%), the LAMS dislodged during the index procedure. A second LAMS was placed in two of these patients, and a through-the-scope fully covered self-expanding metal stent (FCSEMS; 18×60 mm; Taewoong Medical, Goyang, Korea) was deployed in the third patient without any clinical sequelae. One patient (mentioned above) experienced a jejunal perforation during the attempt to advance the duodenoscope through the jejunogastric LAMS to perform ERCP. The perforation was closed with two adjacent OTSCs without the need for surgical intervention. Three months later, the patient decided to undergo LAMS removal in another institution. There were no instances of bleeding, peritonitis, or pancreatitis in any of the study patients.
Weight change
The mean weight change from LAMS insertion to removal was negative 2.85 kg. In patients who gained weight, the average gain was 1.7 kg. In patients who lost weight, the average loss was 6.64 kg.
DISCUSSION
As bariatric procedures continue to grow in popularity and show effectiveness in reducing obesity and its complications, endoscopists are increasingly required to perform a greater number of interventions in patients with altered anatomy. The development of improved techniques for ERCP in these patients is especially important, as nearly 50% of postbariatric surgery patients develop gallstones within 2 years [9]. While there are a number of options for performing ERCP in these patients, including conventional ERCP, EA-ERCP, and LA-ERCP, none of these meet the ideal criteria of being: (1) minimally invasive; (2) able to be performed by a single team; (3) efficacious with a high success rate; and (4) safe with minimal complications. This multicenter experience demonstrates that it is possible to meet all four criteria for an ideal intervention with the use of the EDGE procedure.
It is appropriate to mention that there do exist other fully endoscopic, minimally invasive procedures for accessing the remnant stomach, such as percutaneous-assisted transprosthetic endoscopic therapy (PATENT) [19], EUS-assisted, fluoroscopically guided gastrostomy tube placement [20,21], and external EDGE [22,23]. PATENT consists of advancement of a duodenoscope through an esophageal self-expanding metal stent deployed within a percutaneous gastrostomy tract. While efficacious, the procedure requires deep enteroscopy to access the excluded stomach and the placement of a percutaneous endoscopic gastrostomy (PEG) tube that remains in place for 4 weeks postprocedure. EUS-assisted, fluoroscopically guided gastrostomy tube placement and external EDGE overcome the need for deep enteroscopy by accessing the remnant stomach via EUS, but also require placement of a PEG tube through which conventional ERCP can be performed. While these techniques allow successful, minimally invasive interventions to be performed entirely in the endoscopy suite, they also require PEG tube placement and a minimum of two separate sessions, rendering the techniques unfeasible in patients who require urgent ERCP.
There are notable concerns associated with the utilization of EDGE. The procedure carries a risk of weight gain due to the formation of a gastrogastric or enterogastric fistula, in effect reversing the benefit of the surgical bypass. However, the fistula remains patent for only a short time before closure, and any weight gain would likely be outweighed by the benefit of the procedure. Additionally, in our experience, the mean overall weight change was negative. EDGE may also result in stent dislodgement and potential peritonitis. However, in our experience, no clinical sequelae related to stent dislodgement were observed amongst our patients. Two patients were able to have their LAMS repositioned, and one was bridged with a second FCSEMS. Although one perforation occurred in this series, endoscopic management was possible without the need for surgical intervention, and the patient would likely have undergone successful follow-up ERCP if she had not decided to seek care at another institution.
While the technique is already efficacious, we anticipate that the emergence of novel technological advancements will lead to improvements in the efficacy and overall success of the EDGE procedure. A larger diameter LAMS would facilitate antegrade passage of the duodenoscope through the stent and likely allow for increased rates of ERCP and/or EUS during the same procedure. Similarly, a LAMS containing a cautery feature would negate the need for needle knife dissection and balloon dilation of the fistula tract, and could decrease procedure time and improve efficiency while also improving safety.
Overall, while additional studies are needed to confirm the efficacy and safety of the EDGE procedure, the experience describes here indicates that it is an effective, minimally invasive, single-team, and often single-session solution to the difficulties associated with ERCP in patients who have undergone RYGB.
Conflicts of Interest: Michel Kahaleh has received grant support from Boston Scientific, Fujinon, EMcison, Xlumena Inc., W.L. Gore, MaunaKea, Apollo Endosurgery, Cook Endoscopy, ASPIRE Bariatrics, GI Dynamics, Olympus, NinePoint Medical, Merit Medical, and MI Tech. He is a consultant for Boston Scientific, Xlumena Inc., Concordia Laboratories, Inc., and MaunaKea Tech.
Fig. 1.Endoscopic ultrasound image of endoscopic ultrasound-fine needle aspiration of bypassed stomach.
Fig. 2.Fluoroscopic image of coiling of the wire within the bypassed stomach.
Fig. 3.Endoscopic ultrasound image of deployment of the lumen-apposing metal stent.
Fig. 4.Fluoroscopic image of balloon dilation of the lumen of the lumen-apposing metal stent.
Fig. 5.Endoscopic view of the lumen-apposing metal stent after deployment.
Fig. 6.Fluoroscopic image of endoscopic retrograde cholangiopancreatography through the deployed lumen-apposing metal stent.
Table 1.Endoscopic Ultrasound (EUS)-Directed Transgastric ERCP and/or EUS (n=16)
Technical success |
100% |
Clinical success |
91% (n=10) |
|
5 awaiting fistula maturation prior to ERCP |
|
1 aborted ERCP |
Average hospital stay |
2.7 days |
Major adverse events |
6.25% (n=1): jejunal perforation, managed endoscopically |
Stent dislodgement |
18.75% (n=3) |
|
-2 repositioned |
|
-1 bridged with FCSEMS |
Stent removal and fistula closure |
62.5% (n=10): removed and closed |
|
25% (n=4): stent remains for continued access |
|
6.25% (n=1): patient passed away from unrelated causes prior to stent removal |
|
6.25% (n=1): patient declined further intervention and was lost to follow-up prior to stent removal |
Average weight change |
Negative 2.85 kg |
REFERENCES
- 1. Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004;14:1157–1164.ArticlePubMed
- 2. Buchwald H, Oien DM. Metabolic/bariatric surgery Worldwide 2008. Obes Surg 2009;19:1605–1611.ArticlePubMed
- 3. Ribaric G, Buchwald JN, McGlennon TW. Diabetes and weight in comparative studies of bariatric surgery vs conventional medical therapy: a systematic review and meta-analysis. Obes Surg 2014;24:437–455.ArticlePubMedPMC
- 4. Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 2013;309:2240–2249.ArticlePubMedPMC
- 5. Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741–752.ArticlePubMed
- 6. Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–2693.ArticlePubMed
- 7. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–436.ArticlePubMed
- 8. Hintze RE, Adler A, Veltzke W, Abou-Rebyeh H. Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with billroth II or Roux-en-Y gastrojejunostomy. Endoscopy 1997;29:69–73.ArticlePubMedPDF
- 9. Elton E, Hanson BL, Qaseem T, Howell DA. Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients. Gastrointest Endosc 1998;47:62–67.ArticlePubMed
- 10. Skinner M, Popa D, Neumann H, Wilcox CM, Mönkemüller K. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 2014;46:560–572.ArticlePubMedPDF
- 11. Lopes TL, Clements RH, Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc 2009;70:1254–1259.ArticlePubMed
- 12. Gutierrez JM, Lederer H, Krook JC, Kinney TP, Freeman ML, Jensen EH. Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass. J Gastrointest Surg 2009;13:2170–2175.ArticlePubMed
- 13. Saleem A, Levy MJ, Petersen BT, Que FG, Baron TH. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 2012;16:203–208.ArticlePubMed
- 14. Schreiner MA, Chang L, Gluck M, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 2012;75:748–756.ArticlePubMed
- 15. Shah RJ, Smolkin M, Yen R, et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013;77:593–600.ArticlePubMed
- 16. Choi EK, Chiorean MV, Coté GA, et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013;27:2894–2899.ArticlePubMed
- 17. Kedia P, Sharaiha RZ, Kumta NA, Kahaleh M. Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology 2014;147:566–568.ArticlePubMed
- 18. Kedia P, Tyberg A, Kumta NA, et al. EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc 2015;82:560–565.ArticlePubMed
- 19. Law R, Wong Kee Song LM, Petersen BT, Baron TH. Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy 2013;45:671–675.ArticlePubMedPDF
- 20. Attam R, Leslie D, Freeman M, Ikramuddin S, Andrade R. EUS-assisted, fluoroscopically guided gastrostomy tube placement in patients with Roux-en-Y gastric bypass: a novel technique for access to the gastric remnant. Gastrointest Endosc 2011;74:677–682.ArticlePubMed
- 21. Tekola B, Wang AY, Ramanath M, et al. Percutaneous gastrostomy tube placement to perform transgastrostomy endoscopic retrograde cholangiopancreaticography in patients with Roux-en-Y anatomy. Dig Dis Sci 2011;56:3364–3369.ArticlePubMed
- 22. Kedia P, Kumta NA, Widmer J, et al. Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique. Endoscopy 2015;47:159–163.ArticlePubMedPDF
- 23. Kedia P, Kumta NA, Sharaiha R, Kahaleh M. Bypassing the bypass: EUS-directed transgastric ERCP for Roux-en-Y anatomy. Gastrointest Endosc 2015;81:223–224.ArticlePubMed
Citations
Citations to this article as recorded by
- American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: methodology and review of evidence
Neil B. Marya, Swati Pawa, Nikhil R. Thiruvengadam, Saowanee Ngamruengphong, Todd H. Baron, Anthony Yuen Bun Teoh, Christopher K. Bent, Wasif Abidi, Omeed Alipour, Stuart K. Amateau, Madhav Desai, Jean M. Chalhoub, Nayantara Coelho-Prabhu, Natalie Cosgrov
Gastrointestinal Endoscopy.2024;[Epub] CrossRef - Approaches to Pancreaticobiliary Endoscopy in Roux-en-Y Gastric Bypass Anatomy
Khaled Elfert, Michel Kahaleh
Gastrointestinal Endoscopy Clinics of North America.2024; 34(3): 475. CrossRef - Fixation of the proximal flange of a lumen-apposing metal stent using a through-the-scope endoscopic suturing system to prevent stent migration in single-session EUS-directed transgastric ERCP: a pilot study
Hafiz Muzaffar Akbar Khan, Azhar Hussain, Vishnu Charan Suresh Kumar, Dennis Yang, Muhammad Khalid Hasan
Gastrointestinal Endoscopy.2024; 100(1): 132. CrossRef - Progress in minimally invasive treatment of biliary pancreatic duct obstruction after digestive tract reconstruction by endoscopic retrograde cholangiopancreatography
Ru-Yi Wang, Zhen Fan
World Chinese Journal of Digestology.2024; 32(7): 490. CrossRef - American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: summary and recommendations
Swati Pawa, Neil B. Marya, Nikhil R. Thiruvengadam, Saowanee Ngamruengphong, Todd H. Baron, Anthony Yuen Bun Teoh, Christopher K. Bent, Wasif Abidi, Omeed Alipour, Stuart K. Amateau, Madhav Desai, Jean M. Chalhoub, Nayantara Coelho-Prabhu, Natalie Cosgrov
Gastrointestinal Endoscopy.2024;[Epub] CrossRef - Single‐session endoscopic ultrasound‐directed transgastric endoscopic retrograde cholangiopancreatography with a dedicated over‐the‐scope fixation device: Feasibility study (with video)
Michiel Bronswijk, Emine Gökce, Pieter Hindryckx, Schalk Van der Merwe
Digestive Endoscopy.2024;[Epub] CrossRef - Persistent Fistula Closure After Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography by Postinfarct Ventricular Septal Defect Occluder
Mohamad Aghaie Meybodi, Amitpal S. Johal, Molham Abdulsamad
ACG Case Reports Journal.2024; 11(9): e01519. CrossRef - Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE) Utilization of Trends Among Interventional Endoscopists
Sardar M. Shah-Khan, Eric Zhao, Amy Tyberg, Sardar Sarkar, Haroon M. Shahid, Rodrigo Duarte-Chavez, Monica Gaidhane, Michel Kahaleh
Digestive Diseases and Sciences.2023; 68(4): 1167. CrossRef - Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study
Bachir Ghandour, Margaret G. Keane, Brianna Shinn, Qais M. Dawod, Sima Fansa, Abdul Hamid El Chafic, Shayan S. Irani, Rishi Pawa, Aditya Gutta, Yervant Ichkhanian, Bharat Paranandi, Swati Pawa, Mohammad A. Al-Haddad, Tobias Zuchelli, Matthew T. Huggett, R
Gastrointestinal Endoscopy.2023; 97(2): 260. CrossRef - Suturing a 20-mm lumen-apposing metal stent allows for safe same-session EUS-directed transgastric intervention in patients with Roux-en-Y gastric bypass anatomy: a multicenter study (with video)
Margaret G. Keane, Jennifer T. Higa, Danielle La Selva, Mouen A. Khashab, Shayan S. Irani
Gastrointestinal Endoscopy.2023; 97(2): 291. CrossRef - Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis
Smit S. Deliwala, Babu P. Mohan, Pradeep Yarra, Shahab R. Khan, Saurabh Chandan, Daryl Ramai, Lena L. Kassab, Antonio Facciorusso, Manish Dhawan, Douglas G. Adler, Vivek Kaul, Saurabh Chawla, Gursimran S. Kochhar
Surgical Endoscopy.2023; 37(6): 4144. CrossRef - Risk factors of anastomosis‐related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound‐guided gastro‐gastrostomy using a standardized protocol (with video)
Enrique Pérez‐Cuadrado‐Robles, Hadrien Alric, Lucille Quénéhervé, Laurent Monino, Tigran Poghosyan, Hedi Benosman, Ariane Vienne, Guillaume Perrod, Lionel Rebibo, Ali Aidibi, Elena Tenorio‐González, Emilia Ragot, Mehdi Karoui, Christophe Cellier, Gabriel
Digestive Endoscopy.2023; 35(7): 909. CrossRef - Endoscopic ultrasound-directed transgastric ERCP (EDGE): A multicenter US study on long-term follow-up and fistula closure
Prashant Kedia, Sardar Shah-Khan, Amy Tyberg, Monica Gaidhane, Avik Sarkar, Haroon Shahid, Eric Zhao, Shyam Thakkar, Mason Winkie, Matthew Krafft, Shailendra Singh, Eugene Zolotarevsky, Jeremy Barber, Mitchelle Zolotarevsky, Ian Greenberg, Dhiemeziem Eke,
Endoscopy International Open.2023; 11(05): E529. CrossRef - Endoscopic-Directed Trans-Gastric Retrograde Cholangiopancreatography in Patients With Roux-en-Y gastric Bypasses
Tong Su, Tianjie Chen, Jing Wang, Yuemin Feng, Ruixia Wang, Shulei Zhao
Journal of Clinical Gastroenterology.2023; 57(9): 871. CrossRef - Safety and efficacy of LA-ERCP procedure following Roux-en-Y gastric bypass: a systematic review and meta-analysis
Baraa Saad, Maya Nasser, Reem H. Matar, Hayato Nakanishi, Danijel Tosovic, Christian A. Than, Stephanie Taha-Mehlitz, Anas Taha
Surgical Endoscopy.2023; 37(9): 6682. CrossRef - Clinical application and follow-up of electrocautery-enhanced lumen-apposing metal stents for endoscopic ultrasonography-guided interventions
Yu Mo She, Nan Ge
Annals of Medicine.2023;[Epub] CrossRef - Endoscopic Biliary Drainage in Surgically Altered Anatomy
Marco Spadaccini, Carmelo Marco Giacchetto, Matteo Fiacca, Matteo Colombo, Marta Andreozzi, Silvia Carrara, Roberta Maselli, Fabio Saccà, Alessandro De Marco, Gianluca Franchellucci, Kareem Khalaf, Glenn Koleth, Cesare Hassan, Andrea Anderloni, Alessandro
Diagnostics.2023; 13(24): 3623. CrossRef - Laparoscopic-assisted ERCP following RYGB: a 12-year assessment of outcomes and learning curve at a high-volume pancreatobiliary center
Samer AlMasri, Mazen S. Zenati, Georgios I. Papachristou, Adam Slivka, Michael Sanders, Jennifer Chennat, Mordechai Rabinowitz, Asif Khalid, Andres Gelrud, John Nasr, Savreet Sarkaria, Rohit Das, Kenneth K. Lee, Wolfgang Schraut, Steve J. Hughes, A. James
Surgical Endoscopy.2022; 36(1): 621. CrossRef - Endoscopic ultrasound-directed transgastric ERCP (EDGE): a systematic review describing the outcomes, adverse events, and knowledge gaps
Shaurya Prakash, B. Joseph Elmunzer, Erin M. Forster, Gregory A. Cote, Robert A. Moran
Endoscopy.2022; 54(01): 52. CrossRef - “Innocent as a LAMS”: Does Spontaneous Fistula Closure (Secondary Intention), After EUS-Directed Transgastric ERCP (EDGE) via 20-mm Lumen-Apposing Metal Stent, Confer an Increased Risk of Persistent Fistula and Unintentional Weight Gain?
Matthew Richard Krafft, Alyssa Lorenze, Michael P. Croglio, Wei Fang, Todd H. Baron, John Y. Nasr
Digestive Diseases and Sciences.2022; 67(6): 2337. CrossRef - Biliopancreatic access following anatomy-altering bariatric surgery: a literature review
Pavlos Papasavas, Salvatore Docimo, Rodolfo J. Oviedo, Dan Eisenberg
Surgery for Obesity and Related Diseases.2022; 18(1): 21. CrossRef - Extrapancreatic Advanced Endoscopic Interventions
Haresh Vijay Naringrekar, Haroon Shahid, Cyril Varghese, Alex Schlachterman, Sandeep P. Deshmukh, Christopher G. Roth
RadioGraphics.2022; 42(2): 379. CrossRef - EUS-directed transgastric ERCP: a step-by-step approach (with video)
Michel Kahaleh
Gastrointestinal Endoscopy.2022; 95(4): 787. CrossRef - Comparison of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography outcomes using various technical approaches
Firas Bahdi, Rollin George, Kavea Paneerselvam, Dang Nguyen, Wasif M. Abidi, Mohamed O. Othman, Isaac Raijman
Endoscopy International Open.2022; 10(04): E459. CrossRef - Endoscopic retrieval of a blocked double-pigtail plastic biliary stent through an endoscopic ultrasound-guided gastrojejunostomy in a patient with gastric outlet obstruction
Sridhar Sundaram, Kiran Mane, Unique Tyagi, Aadish Kumar Jain, Utkarsh Chhanchure, Prachi Patil, Shaesta Mehta
Endoscopy.2022; 54(S 02): E806. CrossRef - Endoscopic Approaches to the Management of Biliary Tract Pathology: The Use of Therapeutic Endoscopic Ultrasound
Amy E. Hosmer
Digestive Disease Interventions.2022; 06(03): 197. CrossRef - EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience
Bachir Ghandour, Brianna Shinn, Qais M. Dawod, Sima Fansa, Abdul Hamid El Chafic, Shayan S. Irani, Rishi Pawa, Aditya Gutta, Yervant Ichkhanian, Bharat Paranandi, Swati Pawa, Mohammad A. Al-Haddad, Tobias Zuchelli, Matthew T. Huggett, Michael Bejjani, Ree
Gastrointestinal Endoscopy.2022; 96(4): 630. CrossRef - Endoscopic ultrasound guided access procedures following surgery
Khaled Elfert, Ebrahim Zeid, Rodrigo Duarte-Chavez, Michel Kahaleh
Best Practice & Research Clinical Gastroenterology.2022; 60-61: 101812. CrossRef - Shortened-Interval Dual-Session EDGE Reduces the Risk of LAMS Dislodgement While Facilitating Timely ERCP
Matthew R. Krafft, Wei Fang, John Y. Nasr
Digestive Diseases and Sciences.2021; 66(8): 2776. CrossRef - A comparison of clinical outcomes and cost utility among laparoscopy, enteroscopy, and temporary gastric access-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy
Thomas J. Wang, Pedro Cortes, Pichamol Jirapinyo, Christopher C. Thompson, Marvin Ryou
Surgical Endoscopy.2021; 35(8): 4469. CrossRef - Endoscopic ultrasound-directed transgastric ERCP facilitating extensive ampullectomy in Roux-en-Y gastric bypass patient
Petr Vaněk, Martin L. Freeman, Guru Trikudanathan
Endoscopy.2021; 53(07): E261. CrossRef - Lumen-apposing metal stents for approved and off-label indications: a single-centre experience
Pieter Hindryckx, Helena Degroote
Surgical Endoscopy.2021; 35(11): 6013. CrossRef - Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study
Thomas M. Runge, Austin L. Chiang, Thomas E. Kowalski, Theodore W. James, Todd H. Baron, Jose Nieto, David L. Diehl, Matthew R. Krafft, John Y. Nasr, Vikas Kumar, Harshit S. Khara, Shayan Irani, Arpan Patel, Ryan J. Law, David E. Loren, Alex Schlachterman
Endoscopy.2021; 53(06): 611. CrossRef - Endoscopy in Patients With Surgically Altered Anatomy
Monique T. Barakat, Douglas G. Adler
American Journal of Gastroenterology.2021; 116(4): 657. CrossRef - EUS-directed transgastric ERCP: A first-line option for ERCP following Roux-en-Y gastric bypass
MoniqueT Barakat, DouglasG Adler
Endoscopic Ultrasound.2021; 10(3): 151. CrossRef - Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration
Brianna Shinn, Tina Boortalary, Isaac Raijman, Jose Nieto, Harshit S. Khara, S. Vikas Kumar, Bradley Confer, David L. Diehl, Maan El Halabi, Yervant Ichkhanian, Thomas Runge, Vivek Kumbhari, Mouen Khashab, Amy Tyberg, Haroon Shahid, Avik Sarkar, Monica Ga
Gastrointestinal Endoscopy.2021; 94(4): 727. CrossRef - Endoscopic ultrasound-guided biliary drainage: Are we there yet?
Rishi Pawa, Troy Pleasant, Chloe Tom, Swati Pawa
World Journal of Gastrointestinal Endoscopy.2021; 13(8): 302. CrossRef - Novel Uses of Lumen-apposing Metal Stents
Prashant Bhenswala, Muhddesa Lakhana, Frank G. Gress, Iman Andalib
Journal of Clinical Gastroenterology.2021; 55(8): 641. CrossRef - Biliopancreatic Endoscopy in Altered Anatomy
Ilaria Tarantino, Giacomo Emanuele Maria Rizzo
Medicina.2021; 57(10): 1014. CrossRef - Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review
Alberto Tringali, Deborah Costa, Alessandro Fugazza, Matteo Colombo, Kareem Khalaf, Alessandro Repici, Andrea Anderloni
World Journal of Gastroenterology.2021; 27(44): 7597. CrossRef - Interventional endoscopic ultrasonography in patients with surgically altered anatomy: Techniques and literature review
Akio Katanuma, Tusyoshi Hayashi, Toshifumi Kin, Haruka Toyonaga, Shunsuke Honta, Kouki Chikugo, Hidetaro Ueki, Tastuya Ishii, Kuniyuki Takahashi
Digestive Endoscopy.2020; 32(2): 263. CrossRef - Endoscopic ultrasound-directed transgastric ERCP in patients with Roux-en-Y gastric bypass using lumen-apposing metal stents or duodenal self-expandable metal stents. A European single-center experience
Marina de Benito Sanz, Ana Yaiza Carbajo López, Ramón Sánchez-Ocaña Hernández, Carlos Chavarría Herbozo, Sergio Bagaza Pérez de Rozas, Javier García-Alonso, Carlos de la Serna Higuera, Manuel Pérez-Miranda Castillo
Revista Española de Enfermedades Digestivas.2020;[Epub] CrossRef - Tailored access to the hepatobiliary system in post-bariatric patients: a tertiary care bariatric center experience
Dino Kröll, Alexandra Charlotte Müller, Philipp C. Nett, Reiner Wiest, Johannes Maubach, Guido Stirnimann, Daniel Candinas, Yves Michael Borbély
Surgical Endoscopy.2020; 34(12): 5469. CrossRef - Endoscopic Retrograde Cholangiopancreatography in Patients With Roux-en-Y Gastric Bypass
Erin Forster, B. Joseph Elmunzer
American Journal of Gastroenterology.2020; 115(2): 155. CrossRef - Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Anatomy
Nasim Parsa, Yervant Ichkhanian, Mouen A. Khashab
Current Treatment Options in Gastroenterology.2020; 18(2): 212. CrossRef - Temporary Trans-gastric Stent Deployment Over a 20 French Gastrostomy for Single-Stage Endoscopic Retrograde Cholangiopancreatography After Gastric Bypass
Gianfranco Donatelli, Fabrizio Cereatti, Andrea Spota, Thierry Tuszynski, David Danan, Jean-Loup Dumont
Obesity Surgery.2020; 30(10): 4130. CrossRef - Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos)
Allison R. Schulman, Rabindra R. Watson, Barham K. Abu Dayyeh, Manoop S. Bhutani, Vinay Chandrasekhara, Pichamol Jirapinyo, Kumar Krishnan, Nikhil A. Kumta, Joshua Melson, Rahul Pannala, Mansour A. Parsi, Guru Trikudanathan, Arvind J. Trindade, John T. Ma
Gastrointestinal Endoscopy.2020; 92(3): 492. CrossRef - Endoscopic management of gastric outlet obstruction of remnant stomach in a patient with Roux-en-Y gastric bypass
Vivek Kesar, John Magulick, Varun Kesar, Thiruvengadam Muniraj, Harry R. Aslanian
VideoGIE.2020; 5(11): 557. CrossRef - After you Roux, what do you do? A systematic review of most successful advanced assisted ERCP techniques in patients with various altered upper gastrointestinal surgical anatomical reconstructions with particular focus on RYGB (last 10 years)
Mohamed Elsharif, Adam Gary Hague, Hussam Ahmed, Roger Ackroyd
Clinical Journal of Gastroenterology.2020; 13(6): 985. CrossRef - Endoscopic Ultrasound
Shelini Sooklal, Prabhleen Chahal
Surgical Clinics of North America.2020; 100(6): 1133. CrossRef - Endoscopic approach to gastric remnant outlet obstruction after gastric bypass: A case report
Arash Zarrin, Sufian Sorathia, Vivek Choksi, Steven Robert Kaplan, Franklin Kasmin
World Journal of Gastrointestinal Endoscopy.2020; 12(9): 297. CrossRef - Recent developments in endoscopic ultrasonography-guided gastroenterostomy
Kenjiro Yamamoto, Takao Itoi
International Journal of Gastrointestinal Intervention.2020; 9(4): 177. CrossRef - ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis
Jagpal Singh Klair, Mahendran Jayaraj, Viveksandeep Thoguluva Chandrasekar, Harshith Priyan, Joanna Law, Arvind R. Murali, Dhruv Singh, Michael Larsen, Shayan Irani, Richard Kozarek, Andrew Ross, Rajesh Krishnamoorthi
Endoscopy.2020; 52(10): 824. CrossRef - Bariatric endoscopy: current primary therapies and endoscopic management of complications and other related conditions
Melissa Castro, Alfredo Daniel Guerron
Mini-invasive Surgery.2020;[Epub] CrossRef - Duodenal endoscopic submucosal dissection and sutured defect closure across a lumen-apposing metal stent
Phillip S. Ge, Hiroyuki Aihara, Christopher C. Thompson, Marvin Ryou
VideoGIE.2019; 4(4): 172. CrossRef - Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure
Theodore W. James, Todd Huntley Baron
Obesity Surgery.2019; 29(2): 451. CrossRef - Endoscopic Management of Complex Biliary Stone Disease
Prashant Kedia, Paul R. Tarnasky
Gastrointestinal Endoscopy Clinics of North America.2019; 29(2): 257. CrossRef - ERCP in patients with Roux-en-Y gastric bypass: one size does not fit all
Dennis Yang, Peter V. Draganov
Gastrointestinal Endoscopy.2019; 89(3): 646. CrossRef - Response
Majidah Bukhari, Mouen A Khashab
Gastrointestinal Endoscopy.2019; 89(3): 646. CrossRef - EUS-directed Transgastric ERCP (EDGE) Versus Laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y Gastric Bypass (RYGB) Anatomy
Prashant Kedia, Paul R. Tarnasky, Jose Nieto, Stephen L. Steele, Ali Siddiqui, Ming-ming Xu, Amy Tyberg, Monica Gaidhane, Michel Kahaleh
Journal of Clinical Gastroenterology.2019; 53(4): 304. CrossRef - Advanced Endoscopic Procedures: An Update for Radiologists
Preethi Guniganti, Andrea S. Kierans
American Journal of Roentgenology.2019; 213(2): 332. CrossRef - Endoscopic retrograde cholangiopancreatography in Roux-en-Y gastric bypass patients
Tom G. Moreels
Minerva Chirurgica.2019;[Epub] CrossRef - An adverse event of EUS-directed transgastric ERCP: stent-in-stent technique to bridge the peritoneal gap
Anna Duloy, Hazem Hammad, Raj J. Shah
VideoGIE.2019; 4(11): 508. CrossRef - Accès à l’estomac exclu après by-pass gastrique : expérience d’un centre expert dépourvu de plateau technique permettant la cholangiopancréaticographie rétrograde endoscopique
D. Verscheure, G. Donatelli, P. Tammaro, J.L. Dumont, J.P. Marmuse, K. Arapis
Journal de Chirurgie Viscérale.2018; 155(3): 194. CrossRef - Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass
Ali M. Abbas, Andrew T. Strong, David L. Diehl, Brian C. Brauer, Iris H. Lee, Rebecca Burbridge, Jaroslav Zivny, Jennifer T. Higa, Marcelo Falcão, Ihab I. El Hajj, Paul Tarnasky, Brintha K. Enestvedt, Alexander R. Ende, Adarsh M. Thaker, Rishi Pawa, Priya
Gastrointestinal Endoscopy.2018; 87(4): 1031. CrossRef - Spiral enteroscopy–assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video)
Mohammad F. Ali, Rani Modayil, Krishna C. Gurram, Collin E.M. Brathwaite, David Friedel, Stavros N. Stavropoulos
Gastrointestinal Endoscopy.2018; 87(5): 1241. CrossRef - EUS-guided colo-enterostomy as a salvage drainage procedure in a high surgical risk patient with small bowel obstruction due to severe ileocolonic anastomotic stricture: a new application of lumen-apposing metal stent (LAMS)
Hugh D. Mai, Ethan Dubin, Arun A. Mavanur, Marvin Feldman, Sudhir Dutta
Clinical Journal of Gastroenterology.2018; 11(4): 282. CrossRef - Response to Alkhatib and Alasadi
Allison R. Schulman, Christopher C. Thompson
American Journal of Gastroenterology.2018; 113(5): 777. CrossRef - Single Session EUS-Guided Temporary Gastro-Gastrostomy and ERCP Following Gastric Bypass
Dario Ligresti, Michele Amata, Antonino Granata, Fabio Cipolletta, Luca Barresi, Mario Traina, Ilaria Tarantino
Obesity Surgery.2018; 28(3): 886. CrossRef - Avoidance, Recognition, and Management of Complications Associated with Lumen-Apposing Metal Stents
Stuart K. Amateau, Martin L. Freeman
Gastrointestinal Endoscopy Clinics of North America.2018; 28(2): 219. CrossRef - An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy
Majidah Bukhari, Thomas Kowalski, Jose Nieto, Rastislav Kunda, Nitin K. Ahuja, Shayan Irani, Apeksha Shah, David Loren, Olaya Brewer, Omid Sanaei, Yen-I Chen, Saowanee Ngamruengphong, Vivek Kumbhari, Vikesh Singh, Hanaa Dakour Aridi, Mouen A. Khashab
Gastrointestinal Endoscopy.2018; 88(3): 486. CrossRef - Updates in Therapeutic Endoscopic Ultrasonography
Shawn L. Shah, Manuel Perez-Miranda, Michel Kahaleh, Amy Tyberg
Journal of Clinical Gastroenterology.2018; 52(9): 765. CrossRef - Endoscopic Ultrasound-Guided Creation of a Gastrogastric Conduit After Pancreaticoduodenectomy in a Patient with Prior Roux-en-Y Gastric Bypass
Rohit Das, Herbert Zeh, Amer Zureikat, Adam Slivka, Georgios I. Papachristou
ACG Case Reports Journal.2018; 5(12): e1001. CrossRef - Endoscopic Ultrasound-Guided Creation of a Gastrogastric Conduit After Pancreaticoduodenectomy in a Patient with Prior Roux-en-Y Gastric Bypass
Rohit Das, Herbert Zeh, Amer Zureikat, Adam Slivka, Georgios I. Papachristou
ACG Case Reports Journal.2018; 5(1): e100. CrossRef - Commentary on “Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS”
Se Woo Park
Clinical Endoscopy.2017; 50(2): 102. CrossRef - Techniques for endoscopic retrograde cholangiopancreatography in altered gastrointestinal anatomy
Tom G. Moreels
Current Opinion in Gastroenterology.2017; 33(5): 339. CrossRef - Complications of Bariatric Surgery: What You Can Expect to See in Your GI Practice
Allison R Schulman, Christopher C Thompson
American Journal of Gastroenterology.2017; 112(11): 1640. CrossRef - Endoscopic Evaluation/Management of Bariatric Surgery Complications
Allison R. Schulman, Christopher C. Thompson
Current Treatment Options in Gastroenterology.2017; 15(4): 701. CrossRef