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

Motorized Spiral Enteroscopy (MSE) was introduced into clinical practice and initial trials at expert centres proved it to be safe and effective for deep enteroscopy even in patients with surgically altered anatomy.

Aims & Methods

Prospective study of efficacy and safety of MSE to perform biliary endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy at 5 European centers. Pancreatic indications were excluded. Primary objective: procedural success and serious adverse event (SAE) rate. Secondary objectives: diagnostic and therapeutic yield, procedural time, and patient radiation exposure. The study was prematurely terminated because of MSE withdrawal from the market in July 2023 by the manufacturer (and sponsor of the study). Trial registration: NCT05129449 (clinicaltrials.gov)

Results

89 patients were enrolled, 1 was excluded because of pancreatic indication: 51 (58%) males and 37 (42%) females with mean age of 58 years (range 24-92) and mean bodyweight of 74 kg (range 44-178). Surgically altered anatomy was based on Billroth II reconstruction (29.5%) or Roux-en-Y reconstruction (70.5%), either with naive papilla (39%) or hepaticojejunostomy (61%). Biliary ERCP indications were mainly anastomotic stricture treatment and/or biliary stone removal. 57% of the procedures were performed under general anesthesia with intubation, the remaining under deep sedation. Technical success was defined by the combination of successful enteroscopy followed by cannulation of the bile duct and endoscopic therapy. Enteroscopy was possible in 65/88 patients (74%) in a mean time of 29 min (range 4-104). Bile duct cannulation with cholangiography was possible in 54/88 (61%) and therapeutic ERCP was technically successful in 48/88 (54%). In Billroth II reconstructions technical success was achieved in 13/26 (50%) compared to 35/62 (57%, p=0.0574 Chi square) in Roux-en-Y reconstructions. Technical success was achieved in 17/34 (50%) in patients with intact naive papilla compared to 31/54 (57%, p=0.4968 Chi square) in hepaticojejunostomy. In 21 patients with bariatric Roux-en-Y gastric bypass surgery technical success was 12/21 (57%). In July 2023 the study was prematurely terminated because of MSE withdrawal from the market by the manufacturer because of safety issues. Overall, in 12/88 (14%) patients adverse events (AE) were recorded, of which 6 (7%) were considered serious. Only 1 was related to MSE enteroscopy, 4 to the ERCP procedure and 1 related to the use of a duodenoscope that replaced MSE after reaching the bile duct. MSE enteroscopy-related SAE was a perforation of the proximal oesophagus during MSE insertion. The patient underwent surgical repair and recovered. ERCP-related SAE were cholangitis in 2, sphincterotomy bleeding in 1 and suspicion of air embolism in 1. There was 1 intestinal perforation occurring during duodenoscope insertion that replaced MSE to facilitate ERCP. There was no procedure-related mortality.

Conclusion

This prospective multicentre study was prematurely discontinued due to MSE withdrawal from the market by the manufacturer because of safety issues. In total 88 patients underwent enteroscopy-assisted biliary ERCP in different types of surgically altered anatomy, resulting in an overall technical success rate of 54%. This result is lower as compared to literature data based on balloon-assisted enteroscopy. SAE rate was 7% with only 1 SAE attributable to the use of MSE (oesophageal perforation). MSE allows enteroscopy-assisted ERCP in patients with surgically altered anatomy, but other techniques may be preferred.

Disclosure

The study was sponsored by Olympus Europe (Hamburg).

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.

Variable	Total (n = 26)
Overall technical success, n (%)	25 (96.2)
Overall clinical success, n (%)	25 (96.2)
Persistent fistula (n (%)	0 (0.0)
EDGE-related adverse events, n (%) Stent dislodgment Stent dysfunction Bleeding Perforation duodenal wall	0 (0.0) 0 (0.0) 1 (3.8) 1 (3.8)
ERCP-related adverse events, n (%) Perforation common bile duct Post-ERCP pancreatitis Bleeding	1 (3.8) 1 (3.8) 0 (0.0)
Severity of adverse events Grade I Grade II Grade IIIa Grade IVb	0 (0.0) 2 (7.7) 1 (3.8) 1 (3.8)
Mortality, n (%)	0 (0.0)
Hospital stay, days (IQR)	1 (0 - 2)

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

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

Enteroscopy-assisted ERCP (E-ERCP) is used to treat biliary-enteric anastomotic stricture and common bile duct stones after alimentary tract reconstruction. However, anastomotic stricture usually responds poorly to balloon dilation caused by severe fibrosis. Here, we report a novel technique, endoscopic radial incision (ERI) combined with E-ERCP, to treat biliary-enteric anastomotic stricture and common bile duct stones.

Aims & Methods

From October 2023 to November 2024, six patients with biliary-enteric anastomotic stricture and common bile duct stones who responded poorly to balloon dilation received ERI combined with E-ERCP in Zhongshan Hospital, Fudan University. The primary outcomes were relief of biliary-enteric anastomotic stricture and the removal of common bile duct stones. The secondary outcome was the complication rate of the procedure.

Results

The mean age was 48 and 3 patients were male. All 6 patients successfully received ERI combined with E-ERCP. Four patients with anastomotic stricture were incised by Hook knife, while two patients with the Hook knife not reaching the anastomotic area was incised by the top of the snare. After the ERI, the diameters of the biliary-enteric anastomotic stoma enlarged from 3 mm to 10 mm. The mean diameter of common bile duct stones was 8 mm. All the common bile duct stones were removed by basket catheter successfully, confirmed by intraoperative common bile duct radiography and postoperative MRCP. The mean procedure time was 32 minutes and the mean postoperative hospitalization time was 2 days. No intraoperative and postoperative complications occurred.

Conclusion

ERI combined with E-ERCP, as a novel technique, could be an effective and safe method to treat biliary-enteric anastomotic stricture and common bile duct stones after alimentary tract reconstruction.

Introduction

Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is performed to treat pathology within the biliary system. Patients undergoing this may be on systemic anticoagulation. ERCP is classed as a high-risk bleeding procedure within BSG guidelines. This would necessitate anticoagulation interruption to prevent bleeding. It is recognised however, that resumption of antiplatelets and anticoagulants is associated with improved survival and reduced incidence of thrombotic complications. Thus, all patients should have a clear anticoagulation plan.

Aims & Methods

Attendances for ERCP over a 6-month period were analysed. Of the 132 patients, 33 (25%) were taking either an antiplatelet, warfarin or a Direct Oral Anticoagulant (DOAC). Medical records were reviewed in relation to pre-procedure management of these medications, advice from the endoscopist regarding resumption and whether these medicines were managed appropriately thereafter.
Several interventions were then made; a change to the reporting software led to a prompt relating to antiplatelet/anticoagulant medications, an education campaign for post graduate doctors in training and medication guidance summaries visible in the endoscopy department.
A second 6-month review was then undertaken to evaluate if there had been any improvement in outcomes. In this time frame, 143 patients underwent ERCP of whom 27 (16.7%) were taking antithrombotic therapy.

Results

Results are in Table 1:

	Pre-Intervention	Post Intervention
Pre-procedure appropriate management	48.5%	70.9%
Documented advice on endoscopy report	10%	30%
Post procedure appropriate prescribing	36.3%	70%

One common error was holding of anticoagulation/antiplatelet medication from admission in anticipation of ERCP. This led to long periods off anticoagulation whilst awaiting ERCP.
Documented advice was given more frequently on Endoscopy reports in cases where the patient required further procedure.
It was challenging to analyse post procedural management for inpatients, as the quality of ward round documentation and discharge letters was variable.

Conclusion

Further education to junior staff around utility of BSG anticoagulation guidelines greatly improved pre and post procedure management and thus forms a cornerstone to improve care. Further education to more senior staff may also improve decision rationale and medication advice in ward round documentation and discharge paperwork. Human factors also need to be considered; limited advice is likely related to high endoscopy workload pressures, with sub analysis showing that advice is improved when further intervention is required or in higher risk settings, illustrating that antithrombotic decisions are considered by the endoscopist. Improved documentation at procedure with the support of upgrades to reporting software will enhance post procedure care and consequently reduce demands on the service.​

References

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline updateVeitch AM, Radaelli F, Alikhan R, et al. Gut 2021;70:1611–1628
UEG poster: Improving documented advice regarding anticoagulants and antiplatelets in acute upper gastrointestinal bleeds. Authors: Dr Emily Creed, Dr Vanessa Theis, Dr Katie Clark, Dr Sweekriti Gurung, Dr Abdullah Motam and Dr Gregor Farrell Bins.