Thomas M Runge1, Austin L Chiang2, Thomas E Kowalski2, Theodore W James3, Todd H Baron3, Jose Nieto4, David L Diehl5, Matthew R Krafft6, John Y Nasr6, Vikas Kumar5, Harshit S Khara5, Shayan Irani7, Arpan Patel8, Ryan J Law8, David E Loren2, Alex Schlachterman2, William Hsueh6, Bradley D Confer5, Tyler K Stevens9, Prabhleen Chahal9, Mohammad A Al-Haddad10, Fahad Faisal Mir11, Douglas K Pleskow11, Matthew T Huggett12, Bharat Paranandi12, Arvind J Trindade13, Olaya I Brewer-Gutierrez1, Yervant Ichkhanian1, Mohamad Dbouk1, Vivek Kumbhari1, Mouen A Khashab1. 1. Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. 2. Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA. 3. Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA. 4. Borland Groover Clinic, Advanced Therapeutic Endoscopy Center, Jacksonville, Florida, USA. 5. Department of Gastroenterology, Geisinger Medical Center, Danville, Pennsylvania, USA. 6. Section of Digestive Diseases, Department of Medicine, West Virginia University, Morgantown West Virginia, USA. 7. Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA. 8. Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA. 9. Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA. 10. Division of Gastroenterology, Indiana School of Medicine, Indianapolis, Indiana, USA. 11. Division of Gastroenterology, Department of Medicine, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA. 12. Department of Gastroenterology, St. James' University Hospital, Leeds, UK. 13. Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York, USA.
Abstract
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. Thieme. All rights reserved.
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. Thieme. All rights reserved.
Authors: Matthew Richard Krafft; Alyssa Lorenze; Michael P Croglio; Wei Fang; Todd H Baron; John Y Nasr Journal: Dig Dis Sci Date: 2021-06-29 Impact factor: 3.487