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Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis

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Abstract

Background

In patients with Roux-en-Y gastric bypass (RYGB) anatomy, laparoscopic endoscopic retrograde cholangiopancreatography (LA-ERCP) and enteroscopy-assisted ERCP (E-ERCP) have been utilized to achieve pancreaticobiliary access. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has recently emerged as an alternate and efficient approach. As data regarding EDGE continues to evolve, concerns about safety and efficacy remain, limiting wide adoptability. We performed a systematic review and meta-analysis to assess the safety and efficacy of EDGE and compare it to the current standard of care.

Methods

A comprehensive search of major databases (inception to Nov 2022) identified published studies on EDGE. A random-effects model was used to calculate the pooled rates and heterogeneity (I2). Risk ratio (RR) and standardized difference in means (SMD) were utilized for head-to-head comparison analysis between EDGE vs. LA-ERCP and EDGE vs. E-ERCP. Primary outcomes assessed pooled EDGE safety (adverse events) and efficacy (technical/clinical success). Secondary outcomes assessed efficacy and safety profiles via a comparative analysis of EDGE vs. LA-ERCP and EDGE vs. E-ERCP.

Results

A total of 16 studies (470 patients) were included. EDGE pooled technical success (TS) rate was 96% (95% CI 92–97.6, I2 = 0), and clinical success was 91% (85–95, I2 = 0). Pooled rate of all adverse events with EDGE was 17% (14–24.6, I2 = 32%). On sub-group analysis, these included failure of fistula closure 17% (10–25.5, I2 = 48%), stent migration 7% (4–12, I2 = 51%), bleeding 5% (3.2–7.9, I2 = 0), post-EDGE weight gain 4% (2–9, I2 = 0), perforation 4% (2.1–5.8, I2 = 0), and post-ERCP pancreatitis 2% (1–5, I2 = 0). EDGE TS was comparable to LA-ERCP (97% vs. 98%; RR, 1.00; CI, 0.85–1.17, p = 0.95) and E-ERCP (100% vs. 66%; RR, 1.26; CI, 0.99–1.6, p = 0.06). No statistical difference was noted in adverse events between EDGE and LA-ERCP (13% vs. 17.6%; RR, 0.61; CI, 0.28–1.35, p = 0.52) and E-ERCP (9.6% vs. 16%; RR, 0.61; CI, 0.28–1.35, p = 0.22). EDGE procedure time and hospital stay were shorter than LA-ERCP and E-ERCP (p < 0.001).

Conclusion

Our analysis shows that EDGE is safe and efficacious to the current standard of care. Further head-to-head comparative trials are needed to validate our findings.

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Abbreviations

ASGE:

American society of gastrointestinal endoscopy

CI:

Confidence interval

CTC:

Complete therapeutic cycle

DBE:

Double-balloon enteroscopy

EDGE:

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography

ERCP:

Endoscopic retrograde cholangiopancreatography

E-ERCP:

Enteroscopy-assisted endoscopic retrograde cholangiopancreatography

ESGE:

European society of gastrointestinal endoscopy

EUS:

Endoscopic ultrasound

LAMS:

Lumen-apposing metal stent

LA-ERCP:

Laparoscopy-assisted endoscopic retrograde cholangiopancreatography

MOOSE:

Meta-analysis of observational studies in epidemiology

PEP:

Post-ERCP pancreatitis

PI:

Prediction interval

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

RYGB:

Roux-en-Y gastric bypass

SBE:

Single-balloon enteroscopy

References

  1. Kedia P, Tyberg A, Kumta NA et al (2015) EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc 82:560–565

    Article  PubMed  Google Scholar 

  2. Tyberg A, Nieto J, Salgado S et al (2017) Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc 50:185-190.A

    Article  PubMed  Google Scholar 

  3. Nielsen HJ, Nedrebø BG, Fosså A et al (2022) Seven-year trajectories of body weight, quality of life, and comorbidities following Roux-en-Y gastric bypass and sleeve gastrectomy. Int J Obes (London) 46(4):739–749. https://doi.org/10.1038/s41366-021-01028-5

    Article  CAS  Google Scholar 

  4. Kedia P (2022) Seven years later: do we still have an EDGE? Endoscopy 54(1):62–63

    Article  PubMed  Google Scholar 

  5. Khara HS, Parvataneni S, Park S, Choi J, Kothari TH, Kothari ST (2021) Review of ERCP techniques in Roux-en-Y gastric bypass patients: highlight on the novel EUS-directed transgastric ERCP (EGDE) technique. Curr Gastroenterol Rep 23(7):10

    Article  PubMed  PubMed Central  Google Scholar 

  6. Pawa R, Pleasant T, Tom C, Pawa S (2021) Endoscopic ultrasound-guided biliary drainage: are we there yet? World J Gastrointest Endosc 13(8):302–318

    Article  PubMed  PubMed Central  Google Scholar 

  7. Ayoub F, Brar TS, Banerjee D et al (2020) Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis. Endosc Int Open 8(3):E423–E436

    Article  PubMed  PubMed Central  Google Scholar 

  8. May D, Vogels E, Parker D, Petrick A, Diehl D, Gabrielsen J (2019) Overall outcomes of laparoscopic-assisted ERCP after Roux-en-Y gastric bypass and sphincter of Oddi dysfunction subgroup analysis. Endosc Int Open 7(10):E1276–E1280. https://doi.org/10.1055/a-0832-1898

    Article  PubMed  PubMed Central  Google Scholar 

  9. Dhindsa BS, Dhaliwal A, Mohan BP et al (2020) EDGE in Roux-en-Y gastric bypass: how does it compare to laparoscopy-assisted and balloon enteroscopy ERCP: a systematic review and meta-analysis. Endosc Int Open 8(2):E163–E171

    Article  PubMed  PubMed Central  Google Scholar 

  10. Schreiner MA, Chang L, Gluck M et al (2012) Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 75(4):748–756. https://doi.org/10.1016/j.gie.2011.11.019

    Article  PubMed  Google Scholar 

  11. Inamdar S, Slattery E, Sejpal DV et al (2015) Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc 82(1):9–19

    Article  PubMed  Google Scholar 

  12. Bukhari M, Kowalski T, Nieto J et al (2018) An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc 88:486–494

    Article  PubMed  Google Scholar 

  13. Kedia P, Tarnasky PR, Nieto J et al (2018) EUS-directed transgastric ERCP (EDGE) versus laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y Gastric bypass (RYGB) anatomy: a multicenter early comparative experience of clinical outcomes. J Clin Gastroenterol 53:304

    Article  Google Scholar 

  14. Deliwala SS, Chawla S (2022) Ballooning your way in altered anatomy ERCP: ready for deductive learning. Dig Dis Sci 67:2696–2698. https://doi.org/10.1007/s10620-021-07348-w

    Article  PubMed  Google Scholar 

  15. Law R, Wong Kee Song LM, Petersen BT, Baron TH (2013) Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy 45(8):671–675

    Article  CAS  PubMed  Google Scholar 

  16. Abu DB (2015) Single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy: getting there. Gastrointest Endosc 82(1):20–23

    Article  Google Scholar 

  17. Kedia P, Sharaiha RZ, Kumta NA, Kahaleh M (2014) Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology 147(3):566–568

    Article  PubMed  Google Scholar 

  18. Wang TJ, Cortes P, Jirapinyo P et al (2020) A comparison of clinical outcomes and cost utility among laparoscopy, enteroscopy, and temporary gastric access-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Surg Endosc. https://doi.org/10.1007/s00464-020-07952-3

    Article  PubMed  PubMed Central  Google Scholar 

  19. Connell M, Sun WYL, Mocanu V et al (2022) Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis. Surg Endosc 36:6868–6877. https://doi.org/10.1007/s00464-022-09018-y

    Article  PubMed  Google Scholar 

  20. Khan MA, Kedia P, Tyberg A et al (2018) Mo1338 comparison of eus directed transgastric endoscopic retrograde cholangiopancreatography (edge) with laparoscopic guided endoscopic retrograde cholangiopancreatography in patients with roux-en-y bypass: a meta-analysis. Gastrointest Endosc 87(6):ab452–ab453

    Article  Google Scholar 

  21. Prakash S, Elmunzer BJ, Forster EM, Cote GA, Moran RA (2022) Endoscopic ultrasound-directed transgastric ERCP (EDGE): a systematic review describing the outcomes, adverse events, and knowledge gaps. Endoscopy 54(1):52–61. https://doi.org/10.1055/a-1376-2394

    Article  PubMed  Google Scholar 

  22. van der Merwe SW, van Wanrooij RLJ, Bronswijk M et al (2022) Therapeutic endoscopic ultrasound: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy 54(2):185–205

    Article  PubMed  Google Scholar 

  23. Van Wanrooij RLJ, Bronswijk M, Kunda R et al (2022) Therapeutic endoscopic ultrasound: European society of gastrointestinal endoscopy (ESGE) technical review. Endoscopy 54(3):310–332

    Article  PubMed  Google Scholar 

  24. Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. Ann Intern Med 151:264–269

    Article  PubMed  Google Scholar 

  25. Stroup DF, Berlin JA, Morton SC et al (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 283:2008–12

    Article  CAS  PubMed  Google Scholar 

  26. Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25:603–605

    Article  PubMed  Google Scholar 

  27. Cotton PB, Eisen GM, Aabakken L et al (2010) A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 71:446–454

    Article  PubMed  Google Scholar 

  28. Runge TM, Chiang AL, Kowalski TE et al (2021) Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study. Endoscopy 53:611–618

    Article  PubMed  Google Scholar 

  29. de Benito SM, Carbajo AY, Sánchez-Ocaña Hernández R et al (2020) Endoscopic ultrasound-directed transgastric ERCP in patients with Roux-en-Y gastric bypass using lumen-apposing metal stents or duodenal self-expandable metal stents. A European single-center experience. Rev Esp Enferm Dig 112(3):211–215

    Google Scholar 

  30. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188

    Article  CAS  PubMed  Google Scholar 

  31. Mohan BP, Adler DG (2019) Heterogeneity in systematic review and meta-analysis: how to read between the numbers. Gastrointest Endosc 89:902–903

    Article  PubMed  Google Scholar 

  32. Rothstein HR, Sutton AJ, Borenstein M (2006) Publication bias in meta-analysis: prevention, assessment and adjustments. Wiley, Hoboken

    Google Scholar 

  33. Irani S, Yang J, Khashab MA (2018) Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP. VideoGIE 3:322–324

    Article  PubMed  PubMed Central  Google Scholar 

  34. Hsueh W, Krafft MR, Abdelqader A, Nasr J (2019) Su1167 eus-directed transgastric ercp with 20 mm lumen-apposing metal stents in patients with roux-en-y gastric bypass are we closer to perfection? Gastrointest Endosc 89(6):ab297

    Article  Google Scholar 

  35. Siddiqui A, Murphy M, Shah A et al (2017) 622 An international, multicenter, comparative trial of Eus-guided gastrogastrostomy-assisted Ercp and laparoscopic assisted Ercp in patients with Roux-En-Y gastric bypass anatomy. Gastrointest Endosc 85(5):87–88

    Article  Google Scholar 

  36. Ngamruengphong S, Nieto J, Kunda R et al (2017) Endoscopic ultrasound-guided creation of a transgastric fistula for the management of hepatobiliary disease in patients with Roux-en-Y gastric bypass. Endoscopy 49(6):549–552

    Article  PubMed  Google Scholar 

  37. Ichkhanian Y, Runge T, Jovani M et al (2020) Management of adverse events of EUS-directed transgastric ERCP procedure. VideoGIE 5:260–263

    Article  PubMed  PubMed Central  Google Scholar 

  38. Chiang AL, Gaidhane M, Loren DE et al (2018) 338 Impact of EUS-directed transgastric ercp (edge procedure) access route on technical success and adverse events: a multi-center experience. Gastrointest Endosc 87:70–71

    Article  Google Scholar 

  39. James TW, Baron TH (2019) Endoscopic ultrasound-directed transgastric ERCP (EDGE): a single-center US experience with follow-up data on fistula closure. Obes Surg 29:451–456

    Article  PubMed  PubMed Central  Google Scholar 

  40. Gutta A, Patel HK, Watkins JL, Sherman S, DeWitt J, Lehman G et al (2019) 919 Outcomes of endoscopic ultrasound directed trans-gastric ERCP (EDGE): a single center experience. Am J Gastroenterol 114(1):S537

    Article  Google Scholar 

  41. Krafft MR, Hsueh W, James TW et al (2019) The EDGI new take on EDGE: EUS-directed transgastric intervention (EDGI), other than ERCP, for Roux-en-Y gastric bypass anatomy: a multicenter study. Endosc Int Open 7(10):E1231–E1240

    Article  PubMed  PubMed Central  Google Scholar 

  42. Parvataneni S, Kumar V, Confer B et al (2019) 917 EUS-directed transgastric ERCP (EDGE) versus laparoscopy-assisted ERCP (LAERCP) for Roux-en-Y gastric bypass (RYGB): a single center experience. Off J Am Coll Gastroenterol 114:536

    Article  Google Scholar 

  43. Abidali H, Rezaie A, Omer A et al (2020) su1427 eus-directed transgastric ercp versus double balloon enteroscopy-assisted ercp in patients with roux-en-y gastric bypass anatomy: a single center experience. Gastrointest Endosc 91(6):340–341

    Article  Google Scholar 

  44. Kochhar GS, Mohy-Ud-Din N, Grover A et al (2020) EUS-directed transgastric endoscopic retrograde cholangiopancreatography versus laparoscopic-assisted ERCP versus deep enteroscopy-assisted ERCP for patients with RYGB. Endosc Int Open 8:E877-e882

    Article  PubMed  PubMed Central  Google Scholar 

  45. Nguyen NQ, Nett A, Hamerski CM et al (2020) su1425 impact of eus guided gastro-gastrostomy to facilitate further endoscopic interventions in patients with roux-en-y gastric bypass: more than just edge! Gastrointest Endosc 91(6):ab340

    Article  Google Scholar 

  46. Tyberg A, Kedia P, Tawadros A et al (2020) EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE): the first learning curve. J Clin Gastroenterol 54:569–572

    Article  CAS  PubMed  Google Scholar 

  47. Bahdi F, George R, Paneerselvam K et al (2022) Comparison of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography outcomes using various technical approaches. Endosc Int Open 10(4):E459–E467

    Article  PubMed  PubMed Central  Google Scholar 

  48. Simons-Linares CR, Chahal P (2019) ERCP through gastrogastric fistula in a patient with Roux-en-Y gastric bypass anatomy. Obes Surg 29:1370–1371

    Article  PubMed  Google Scholar 

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Acknowledgements

We thank Dana Gerberi, MLIS, Librarian, and Mayo Clinic Libraries for help with the literature search.

Funding

None.

Author information

Authors and Affiliations

  1. Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA

    Smit S. Deliwala & Saurabh Chawla

  2. Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, UT, USA

    Babu P. Mohan & Daryl Ramai

  3. Internal Medicine, University of Kentucky, Lexington, KY, USA

    Pradeep Yarra

  4. Harvard School of Medicine, Boston, MA, USA

    Shahab R. Khan

  5. Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, NE, USA

    Saurabh Chandan

  6. Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Lena L. Kassab

  7. Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy

    Antonio Facciorusso

  8. Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, PA, USA

    Manish Dhawan & Gursimran S. Kochhar

  9. Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA

    Douglas G. Adler

  10. Division of Gastroenterology & Hepatology, University of Rochester Medical Center, Rochester, NY, USA

    Vivek Kaul

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Contributions

GSK, BPM, SD: Conception and design, interpretation of the data, drafting of the article, and intellectual content. GSK, SC, SC, DA, VK, DR, AF: final approval of the manuscript. SD, SRK, PY, SC: study search, review, and selection. SD, SRK, PY, SC: data collection and synthesis. SD, BPM, PY, DR, AF: statistical analysis of data and interpretation of results. All authors: critical revision of the article for important intellectual content and final approval of the article.

Corresponding author

Correspondence to Smit S. Deliwala.

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Disclosures

Smit S. Deliwala MD, Pradeep Yarra MD MPH, Shahab R. Khan MBBS, Saurabh Chandan MD, Daryl Ramai MD MSc, Lena L. Kassab MD MBA, Antonio Facciorusso MD PhD, Manish Dhawan MD, Douglas G. Adler MD, Vivek Kaul MD, Saurabh Chawla MD and Gursimran S. Kochhar MD has no conflicts of interest or financial ties to disclose.

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Deliwala, S.S., Mohan, B.P., Yarra, P. et al. Efficacy & safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review & meta-analysis. Surg Endosc 37, 4144–4158 (2023). https://doi.org/10.1007/s00464-023-09926-7

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