Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

Background and Aims The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases yet standard ERCP is not possible due to surgically altered gastroduodenal anatomy. Laparoscopic-ERCP (LA-ERCP) has been proposed as an option but supporting data are derived from single center small case-series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. Methods This is retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all of the following were achieved: reaching the papilla, cannulating the desired duct and providing endoscopic therapy as clinically indicated. Results A total of 579 patients (median age 51, 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (IQR 109-210) with median ERCP time 40 minutes (IQR 28-56). Median hospital stay was 2 days (IQR 1-3). Adverse events were 18% (laparoscopy-related 10%, ERCP-related 7%, both 1%) with the clear majority (92%) classified as mild/moderate whereas 8% were severe and 1 death occurred. Conclusion Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher due to the added laparoscopy-related events

Single-Operator Peroral Cholangioscopy for Extraction of Cystic Duct Stones in Postcholecystectomy Mirizzi Syndrome

Mirizzi syndrome is an exceptionally rare diagnosis with an annual incidence of less than 1% in developed countries. In this disease process, stone burden in the cystic duct or gallbladder neck leads to common hepatic duct obstruction, either by mechanical compression or secondary inflammation. Mirizzi syndrome is classified into one of four types based on the presence and severity of cholecystobiliary fistulization. Treatment is primarily surgical in nature and largely dictated by the type of Mirizzi syndrome encountered. It is typically diagnosed in the preoperative or operative setting of cholecystectomy; however, there have been rare occurrences of postcholecystectomy diagnosis. Factors thought to predispose to postcholecystectomy disease include low insertion of the cystic duct and long remnant duct length. Few case reports exist describing this phenomenon and its management, which is made exceptionally difficult due to the presence of inflammation and surgical adhesion. We present the case of a young female with postcholecystectomy Mirizzi syndrome who underwent successful endoscopic management using peroral cholangioscopy and electrohydraulic lithotripsy. We also provide a brief overview of both Mirizzi syndrome and peroral cholangioscopy

Radical approach to traumatic tracheoesophageal fistula: Use of a biliary stent for esophageal repair in an infant

Background: The incidence of button battery ingestion has increased over time along with its most alarming complications including tracheoesophageal fistula. Historically this issue has been treated with sternotomy and closure of the fistula. However, morbidity and mortality of this invasive approach can be improved upon. Methods: This is an expert report from a tertiary care center, utilizing an adult biliary stent for closure of a giant 2 cm traumatic TEF secondary to a button battery ingestion in a 9 month old. Results: The patient's fistula healed with this radical approach and demonstrated a full return to swallowing, without invasive operative interventions. Conclusion: We present a radical approach with successful treatment of a TEF. This is the first study of its kind to utilize adult biliary stents for closure of a traumatic TEF in an infant. Level of evidence: V

A location-based anatomic classification system for acute pancreatic fluid collections: Roadmap for optimal intervention in the step-up era

Walled-off pancreatic necrosis (WOPN) is a local complication of acute necrotizing pancreatitis frequently requiring intervention. Treatment is typically through the coordinated efforts of a multidisciplinary team. Current management guidelines recommend a step-up approach beginning with minimally invasive techniques (percutaneous or transmural endoscopic drainage) followed by escalation to more invasive procedures if needed. Although the step-up approach is an evidence-based treatment paradigm for management of pancreatic fluid collections, it lacks guidance regarding optimal invasive technique selection based on the anatomic characteristics of pancreatic fluid collections. Similarly, existing cross-sectional imaging-based classification systems of pancreatic fluid collections have been used to predict disease severity and prognosis; however, none of these systems are designed to guide intervention. We propose a novel classification system which incorporates anatomic characteristics of pancreatic fluid collections (location and presence of disconnected pancreatic duct) to guide intervention selection and clinical decision making. We believe adoption of this simple classification system will help streamline treatment algorithms and facilitate cross-study comparisons for pancreatic fluid collections

Factors predictive of persistent fistulas in EUS-Directed transgastric ERCP: A multicenter matched case-control study

BACKGROUND: EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However widespread adoption of the technique has been limited due to concerns about the development of persistent gastrogastric (GG) or jejunogastric (JG) fistulas. GG/GJ fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management/outcomes are lacking. AIMS: To assess (1) factors associated with the development of persistent fistulas; (2) technical success of endoscopic fistula closure. PATIENTS AND METHODS: This is a case-control study involving 9 centers (8 USA, 1 Europe) from 02/2015 to 09/2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Controls were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined/graded according to ASGE lexicon. RESULTS: 25 patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (controls) based on age and sex. Mean LAMS dwell time was 74.7±106.2d. Following LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 (61.3%). Primary closure of the fistula was performed in 26.7% (n=20, endoscopic suturing in 17, endoscopic tacking in 2 and over-the-scope clips + endoscopic suturing in 1). When comparing cases to controls, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the two groups (p\u3e0.05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 d vs 48 d, p=0.02), and more patients had ≥5% total body weight gain (33.3% vs 10.3%; p=0.03). LAMS dwell time was a significant predictor of persistent fistula (OR=4.5 after \u3e40 days in situ, p=0.01). The odds of developing a persistent fistula increased by 9.5% for every 7 days that the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 76% (n=19) with successful resolution in 14 (73.7%). CONCLUSIONS: Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which if present, can be effectively managed through endoscopic closure in most cases

EUS-directed transgastric interventions in Roux-En-Y Gastric Bypass anatomy: a multicenter experience

Background and Aims Placement of a Lumen Apposing Metal Stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS Guided Transgastric Interventions (EDGI) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS guided transgastric ERCP (EDGE) outcomes have been reported, there is a paucity of data on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGI. Methods This is a retrospective study involving 9 centers (8 USA, 1 Europe) and included patients with RYGB who underwent EDGI between 06/2015 and 09/2021. The primary outcome was the technical success of EDGI. Secondary outcomes included adverse events, length of hospital stay, and fistula follow-up and management. Results 54 EDGI procedures were performed in 47 patients (mean age 61yr, F 72%), most commonly for the evaluation of a pancreatic mass (n=16) and management of pancreatic fluid collections (n=10). A 20mm LAMS was utilized in 26 patients and a 15mm LAMS in 21, creating a gastrogastrostomy (GG) in 37 patients and jejunogastrostomy (JG) in 10. Most patients (n=30, 64%) underwent a dual-session EDGI, with a median interval of 17d between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (+/-FNA/B) (n=28) and EUS-guided cystgastrostomy (n=8). The mean procedural time was 97.6 ± 78.9 mins. Technical success was achieved in 52 (96%). AEs occurred in 5 (10.6%) patients, of which only 1 (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), while delayed spontaneous LAMS migration occurred in 2 (4.3%). 4 of the 5 LAMS migration events were managed endoscopically, and one required surgical repair. LAMS anchoring was found to be protective against LAMS migration (p=0.001). The median duration of hospital stay was 2.1 ± 3.7d. Of the 17 patients who underwent objective fistula assessment endoscopically/radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In one case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. Conclusion EDGI is effective and safe for the diagnosis and management of pancreatobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems effective