Introduction

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy represents a real challenge for endoscopists. The most widely used options for ERCP in these cases are enteroscopy-assisted ERCP (EA-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and endoscopic ultrasound-directed ERCP (EDGE).

Aims & Methods

Our aim is to compare EA-ERCP, LA-ERCP, and EDGE in terms of safety and efficacy by performing a systematic review and meta-analysis. The protocol was registered beforehand with PROSPERO (ID: CRD42022368788). We systematically searched three medical databases, namely MEDLINE (via PubMed), Embase, and Cochrane CENTRAL, to look for studies investigating EA-ERCP, LA-ERCP, or EDGE. We performed indirect comparison to compare the interventions based on comparative and single-arm studies. Proportions were calculated by pooling together event rates with 95% confidence intervals (CI). Differences between interventions were considered significant if p<0.05. Random-effect model was used to pool effect sizes.

Results

In total, 67 studies were included (2,714 patients). The technical success rate was 78% (CI: 0.71-0.83) for EA-ERCP, 93% (CI: 0.9-0.95) for LA-ERCP, and 96% (CI: 0.92-0.98) for EDGE with total heterogeneity (I²) 0%. Subgroup differences were significant between EA-ERCP and EDGE or LA-ERCP groups, p < 0.05. The clinical success rate was 65% (CI: 0.58-0.73) for EA-ERCP, 92% (CI: 0.89-0.94) for LA-ERCP, and 93% (CI: 0.88-0.97) for EDGE, I²: 18%, p< 0.05. Overall adverse event rates were 12% (CI: 0.7-0.21), 19% (CI: 0.14-0.24), and 20% (CI: 0.12-0.31), respectively with I²: 60%, p= 0.343.

Conclusion

EA-ERCP performed poorly compared to LA-ERCP and EDGE regarding technical and clinical success rates, with no significant difference in adverse event rates. Our results question he role of EA-ERCP in the RYGB population.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently indicated in patients who underwent Roux-en-Y gastric bypass (RYGB) surgery. (1, 2) However, due to the altered anatomy, it is challenging to gain pancreatobiliary access in patients following a RYGB. Several strategies are currently available, but all have their disadvantages. Laparoscopy-assisted ERCP (LA-ERCP), the current golden standard, has higher success rates but also comes with logistical challenges of intraoperative ERCP, peri-operative complications and high costs. (3 - 5) Endoscopic ultrasound directed ERCP (EDGE) is a technique used to create a gastro-gastrostomy by placing a lumen apposing metal stent (LAMS) between the gastric pouch and the excluded stomach, facilitating subsequent ERCP.(6) Although EDGE gained more popularity over the last few years, prospective studies are lacking.

Aims & Methods

The aim of this study is to provide prospective evidence for the efficacy and safety of EDGE, including fistula closure.This multicentre prospective cohort study included all consecutive patients scheduled for elective ERCP after RYGB surgery. EDGE was performed as a two-step procedure. Primary endpoint was overall technical success. Secondary endpoints were technical success of LAMS placement and ERCP individually, persistent fistula and other procedure-related adverse events (AEs).

Results

Between January 2021 and August 2024, 26 patients were included in 4 Dutch hospitals. Overall technical success was achieved in 25/26 patients (96.2%). Median LAMS indwelling time was 14 days [IQR 11 – 28 days]. Two EDGE-related AEs occurred (7.7%); one perforation of the contralateral duodenal wall following scope insertion and one bleeding after LAMS placement. Two ERCP-related AEs occurred (7.7%): one CBD perforation and one post-ERCP pancreatitis. Two patients were lost to follow-up. None of the remaining patients had a persistent fistula, based on radiologic or endoscopic evidence (0/24). No mortality occurred.

Conclusion

This prospective study shows that two-step EDGE is relatively safe and associated with high technical success, without any cases of a persistent fistula. However, AEs occurred in 4 patients (15.4%), of which two were EDGE-related (7.7%).

References

1. Yang H, Petersen GM, Roth MP, Schoenfield LJ. Risk factors for gallstone formation during rapid loss of weight. Digestive diseases and sciences. 1992;37(6):912-8.
2. Haal S, Guman MSS, Boerlage TCC, Acherman YIZ, de Brauw LM, Bruin S, et al. Ursodeoxycholic acid for the prevention of symptomatic gallstone disease after bariatric surgery (UPGRADE): a multicentre, double-blind, randomised, placebo-controlled superiority trial. Lancet Gastroenterol Hepatol. 2021;6(12):993-1001.
3. Gangwani MK, Aziz M, Haghbin H, Iqbal A, Dillard J, Dahiya DS, et al. Comparing EUS-directed Transgastric ERCP (EDGE) Versus Laparoscopic-Assisted ERCP Versus Enteroscopic ERCP: A Network Meta-analysis. J Clin Gastroenterol. 2024;58(2):110-9.
4. da Ponte-Neto AM, Bernardo WM, de ACLM, Josino IR, Brunaldi VO, Moura DTH, et al. Comparison between Enteroscopy-Based and Laparoscopy-Assisted ERCP for Accessing the Biliary Tree in Patients with Roux-en-Y Gastric Bypass: Systematic Review and Meta-analysis. Obes Surg. 2018;28(12):4064-76.
5. Abbas AM, Strong AT, Diehl DL, Brauer BC, Lee IH, Burbridge R, et al. Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Gastrointestinal endoscopy. 2018;87(4):1031-9.
6. van Wanrooij RLJ, Bronswijk M, Kunda R, Everett SM, Lakhtakia S, Rimbas M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy. 2022;54(3):310-32.

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. Despite the central role of bile duct cannulation in procedural success and safety, data on influencing factors remain limited. Cannulation outcomes can be affected by periampullary diverticula (PAD), anatomical variations, and the experience of the endoscopist. Our previous meta-analysis and systematic review identified papilla morphology as a significant contributing factor. Further research suggests that different papilla types may influence technical success and complication rates, including post-ERCP pancreatitis (PEP). Moreover, papilla morphology appears to impact both the need for and choice of rescue cannulation techniques, making its evaluation particularly relevant in clinical practice.

Aims & Methods

This study aims to evaluate how papilla morphology affects ERCP outcomes, including cannulation success, rescue techniques, and complications like post-ERCP pancreatitis (PEP). We conducted a retrospective cohort study at a tertiary care center, reviewing patients with native papilla scheduled for ERCP between September 2022 and August 2024. Papillae were classified according to the Haraldsson system into four types. Demographic, clinical, and procedural outcome data were collected, including complications such as PEP. Rescue techniques included transpancreatic sphincterotomy (TPS), needle-knife papillotomy (NKP), needle-knife fistulotomy (NKF), and double guidewire technique (DGT). Descriptive statistics were used to analyze the data.

Results

A total of 409 patients with native papilla were included in the study. Cannulation failure rates varied across papilla types, being highest in type II papilla (15.6%), followed by type I (9.1%), type IV (8.1%), and type III (4.4%). The rate of PAD was highest in type IV papillae (13.5%) and lowest in type III (4.4%). Biliary etiology was the leading indication for ERCP across all papilla types, with rates of 60.6% for type I, 59.4% for type II, 66.7% for type III, and 56.8% for type IV. PEP occurred most frequently in type IV papillae (10.8%), followed by type III (6.7%), type I (6.5%), and type II (4.2%). Other complications, including cholangitis, perforation, and bleeding, were rare, with rates of 1.73% for type I and 2.08% for type II papillae, while none occurred in type III or IV papillae. Rescue cannulation techniques were most frequently required in type III papillae (46.7%), where the most common methods included transpancreatic sphincterotomy and needle-knife papillotomy, both of which were used in 20% of cases. The double guidewire technique was employed in 15.6% of type III cases, while needle-knife fistulotomy was used in 6.7%. Type I and type IV papillae also had significant rates of rescue cannulation (40.7% and 40.5%, respectively), with needle-knife papillotomy being the most commonly used method in both types (19.9% for type I and 24.3% for type IV). For type I papillae, TPS was used in 16% of cases, while the DGT was the preferred method for type IV papillae in 13.5% of cases. Rescue techniques were less frequently needed for type II papillae (29.2%), with DGT being the most commonly applied (10.4%), followed by TPS (9.4%) and NKP (8.3%).

Conclusion

Papilla morphology affects ERCP outcomes and the choice of rescue cannulation techniques. Types III and IV were associated with higher use of advanced techniques and complication rates. Identifying papilla type may support individualized procedural planning and improve success and safety.

Introduction

Biliary and gastric outlet obstruction (GOO) are common complications in patients with pancreatic cancer, often delaying essential cancer treatments. While endoscopic ultrasound-guided
gastroenterostomy (EUS-GE) has been shown to be superior to duodenal self-expandable metal stents (dSEMS) for managing GOO, the optimal strategy for biliary drainage (BD) in this setting remains unclear. Specifically, there is no consensus on whether to prefer EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided hepaticogastrostomy (EUS-HGS).

Aims & Methods

We conducted a systematic review and meta-analysis to identify the optimal biliary drainage approach in patients undergoing EUS-GE for concomitant GOO and biliary obstruction. We searched Medline, Scopus, and EMBASE up to February 2025. Studies were included if they reported outcomes of EUS-CDS or EUS-HGS in patients with biliary obstruction and concomitant GOO
treated by EUS-GE. Pooled outcomes included technical and clinical success, stent dysfunction, and adverse events, analyzed using a random-effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs).

Results

Five studies met inclusion criteria, comprising 128 patients (female = 45.5%; mean age range 63.0–73.0 years), with 61 undergoing EUS-CDS and 67 undergoing EUS-HGS. Four studies were conducted in Europe and one in the United States; one study was prospective. Technical success rates were similar between groups (RR 0.96, 95% CI 0.83–1.11; I² = 0%; EUS-CDS 94.5% vs EUS-HGS 96.4%), as were clinical success rates (RR 1.04, 95% CI 0.92–1.19; I² = 0%; EUS-CDS 96.5% vs EUS-HGS 89.1%). However, the risk of stent dysfunction was significantly higher in the EUS-CDS group compared to EUS-HGS (RR 4.42, 95% CI 1.71–11.43; I² = 0%; EUS-CDS 45.1% vs EUS-HGS 10.9%). The incidence of procedure-related adverse events was comparable between the two approaches (RR 1.14, 95% CI 0.24–5.50; I² = 40.8%; EUS-CDS 10.7% vs EUS-HGS 16.0%).

Conclusion

This meta-analysis suggests that both EUS-CDS and EUS-HGS are similarly safe and effective for managing malignant biliary obstruction in the setting of concomitant GOO. However, EUS-CDS is associated with a more than four-fold increase in the risk of stent dysfunction, which may result in delays to critical cancer treatments.

Disclosure

None

Introduction

Postsurgical upper gastrointestinal anatomy impedes access to the biliary system in case an appropriate intervention is needed. Motorized spiral enteroscopy (MSE) was shown feasible in patients with altered anatomy and has the advantage that standard ERCP instruments can be used. Therefore, MSE-ERCP appears to be the optimal solution for postsurgical patients, especially with long limb anatomy.

Aims & Methods

We retrospectively analyzed all MSE-ERCP procedures performed in patients with Roux-en-Y reconstruction between September 2021 and October 2022 in our hospital.

Results

We identified 18 MSE-ERCP procedures (9 in long afferent limb situation – e.g. after gastrectomy or hepaticojejunostomy; 9 in very long limb situation – e.g. gastric bypass) in a total of 14 patients. In 14/18 MSE-ERCPs (78%) the papilla/hepatico-jejunostomy was reached and in 12/14 MSE-ERCPs (86%) the intended “standard” ERCP-interventions (e.g. cholangiography, endoscopic papillotomy, biopsy, balloon-dilation, stone-removal, plastic as well as fully covered metal stent-insertion) were successfully performed. Success of reaching the biliary entry was lower in very long limb-situations (66% vs 89%), success of interventions was comparable in both limb situations. Observed complications were caused either by enteroscopy in one patient or by the biliary intervention inanother patient. Mean procedure time for successful interventions was 93 minutes. In 60% of patients MSE-ERCP was carried out on an outpatient basis.

Conclusion

MSE-ERCP is a promising technique for patients with Roux-en-Y reconstructions with good success and acceptable complication rates. Prolonged examination times have to be taken into account and outpatient application is possible in the majority of cases.

Disclosure

Speakers honoria for Olympus, Janssen Pharmaceuticals, Medtronic Ag.

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most commonly used therapeutic procedure for pancreaticobiliary disorders. Despite the essential role of bile duct cannulation in procedural safety and success, research on this topic is still limited. Certain studies suggest that the anatomy of the papilla affects its efficacy and safety.

Aims & Methods

We aimed to assess the influence of papilla morphology on ERCP outcomes and adverse events.
Patients with a naive papilla scheduled for ERCP were reviewed in a single tertiary care center between September 2022 and January 2023. The papilla was classified into one of four types using the Haralddson classification system. Data on the presence of a periampullary diverticulum (PAD) was also assessed. The indications for ERCP, the rate of post-ERCP adverse events (pancreatitis, bleeding, and perforation), the rate of failed cannulation, and the need and type for rescue cannulations were collected. For the effect size measure, event rates or risk ratios were calculated. For categorical data, the χ² test, and for the test of subgroup (papilla type) differences, a "Cochrane Q" test was used.

Results

A total of 231 patients with naive papillae were included. We found a statistically significant difference in the event rate for cannulation failure between the different papilla types. The highest rate was observed in the case of type II („small”) papilla (14%), followed by type I („regular”) (13%) and type III („protruding or bulging”) (8%). The event rate was lowest in the case of type IV („creased or ridged”) papilla (6%). The presence of PAD was associated with a higher risk of cannulation failure (RR: 2.64; CI: 1.22 – 5.39).
Moreover, a statistically significant difference in the rate of post-ERCP pancreatitis was observed between the papilla types. The event rate was the highest in type III („protruding or bulging”) and IV („creased or ridged”) papilla (13%). The lowest rate rate was observed in type I („regular”) and II („small”) papillae, 6%. There was no significant difference between the post-ERCP bleeding and perforation rate in the different papilla types, likely due to the low event number. The need and the types of the various rescue cannulation techniques also significantly differed between the papilla types.

Conclusion

Certain papilla morphologies are associated with a higher rate of cannulation failure and PEP. The presence of PAD is also associated with an increased rate of cannulation failure. Moreover, we can conclude that the preferred rescue cannulation technique differs between the papilla types.