Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Feb;29(2):451-456.
doi: 10.1007/s11695-018-3531-2.

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure

Theodore W James  1 , Todd Huntley Baron  2
Affiliations

Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE): a Single-Center US Experience with Follow-up Data on Fistula Closure

Theodore W James et al. Obes Surg. 2019 Feb.

Abstract

Background: Endoscopic ultrasound-directed transgastric ERCP (EDGE) by creating an anastomosis from the gastric pouch or jejunum to the excluded stomach allows performance of ERCP in Roux-en-Y gastric bypass (RYGB) anatomy. Concern for persistent fistula following stent removal and sparse data limit adoption.

Methods: Retrospective review of consecutive patients undergoing EDGE over a 2-year period.

Results: Nineteen RYGB patients underwent EDGE; three had previously failed ERCP by the device-assisted method. Indications for ERCP were choledocholithiasis (8), recurrent acute pancreatitis (6), benign post-surgical stricture (3), elevated bilirubin, and papillary stenosis (1 each). EDGE was technically successful in all 19 patients with jejunogastric anastomosis in 11 patients and gastrogastric in 8 using a 15-mm lumen-apposing metal stent. Stent malposition occurred in six and was managed by rescue maneuvers. ERCP was performed in the same session in four patients; the remainder were delayed after a mean of 48 days. Diagnostic endoscopic ultrasound (EUS) was performed in four patients. No severe adverse events occurred; clinical success was 100%. Stents were removed after a mean dwell time of 182 days. Argon plasma coagulation (APC) was used to promote fistula closure in 12 patients. Upper GI series to assess fistula closure was obtained in 11 patients after a mean of 182 days following stent removal. One persistent fistula was identified and closed endoscopically.

Conclusions: EDGE is an effective modality for performing ERCP in patients with RYGB anatomy and can be performed via gastrogastric or jejunogastric approaches. Persistent fistula is uncommon and can be managed endoscopically. APC may promote fistula closure.

Keywords: EDGE; ERCP; EUS-GG-ERCP; Endoscopic ultrasound; Gastric bypass; Roux-en-Y.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest: Dr. Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy and Olympus America. Dr. James has no conflicts of interest.

Figures

Figure 1
Figure 1
Jejunogastric fistula with spontaneous closure around a plastic stent prior to removal and treatment with APC.
Figure 2
Figure 2
Upper GI series demonstrating patent jejunogastric fistula following stent removal.
Figure 3
Figure 3
Upper GI series demonstrating closure of jejunogastric fistula following argon plasma coagulation and over-the-scope clip placement to fistulous tract opening.
See this image and copyright information in PMC

References

    1. Esteban Varela J, Nguyen NT. Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers. Surg Obes Relat Dis. 2015;11(5):987–990. - PubMed
    1. Shiffman ML, Sugerman HJ, Kellum JM, Brewer WH, Moore EW. Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am J Gastroenterol. 1991;86(8):1000–1005. - PubMed
    1. Nagem RG, Lázaro-da-Silva A, de Oliveira RM, Morato VG. Gallstone-related complications after roux-en-y gastric bypass: A prospective study. Hepatobiliary Pancreat Dis Int. 2012;11(6):630–635. - PubMed
    1. Banerjee N, Parepally M, Byrne TK, Pullatt RC, Coté GA, Elmunzer BJ. Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis. 2017;13(7):1236–1242. - PubMed
    1. Skinner M, Popa D, Neumann H, Wilcox CM, Mönkemüller K. ERCP with the overtube-assisted enteroscopy technique: A systematic review. Endoscopy. 2014;46(7):560–572. - PubMed

Publication types

MeSH terms