Risk factors of anastomosis‐related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound‐guided gastro‐gastrostomy using a standardized protocol (with video)

Abstract

ObjectivesLittle is known about how to perform the endoscopic ultrasound (EUS)‐directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen‐apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis‐related difficult ERCP.MethodsObservational single‐center study. All patients who underwent an EDGE procedure in 2020–2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed.ResultsForty‐five ERCPs were performed in 31 patients (57.4 ± 8.2 years old, 38.7% male). The EUS procedure was done using a wire‐guided technique (n = 28, 90.3%) for biliary stones (n = 22, 71%) in most cases. The location of the anastomosis was gastro‐gastric (n = 24, 77.4%) and mainly in the middle‐excluded stomach (n = 21, 67.7%) with an oblique axis (n = 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n = 8), anastomotic dilation (n = 8), or failure to pass (n = 3). By multivariable analysis adjusted by two‐stage procedures, the risk factors for a difficult ERCP were the jejuno‐gastric route (85.7% vs. 16.7%; odds ratio [ORa] 31.875; 95% confidence interval [CI] 1.649–616.155; P = 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676–306.570; P = 0.019). There was only one complication (3.2%) and one persistent gastro‐gastric fistula (3.2%) in a median follow‐up of 4 months (2–18 months), with no weight regain (P = 0.465).ConclusionsThe jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.