Skip to main content
SpringerLink
Log in

Trans-Gastric ERCP After Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Background

Trans-oral endoscopic access to the pancreaticobiliary system is challenging after Roux-en-Y gastric bypass (RYGB). Trans-gastric ERCP (TG-ERCP) has emerged as a viable option to manage patients with symptomatic post-RYBG choledocolithiasis. The aim of this systematic review and meta-analysis was to examine the outcomes of TG-ERCP to better define the risk-benefit ratio of this procedure and to guide clinical decision-making.

Methods

A literature search was conducted to identify all reports on ERCP after RYGB. Pubmed, MEDLINE, Embase, and Cochrane databases were thoroughly consulted matching the terms “ERCP” AND “gastric bypass.” Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were calculated using Freeman-Tukey double arcsine transformation and DerSimonian-Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I2-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders.

Results

Thirteen papers published between 2009 and 2017 matched the inclusion criteria. Eight hundred fifty patients undergoing 931 procedures were included. The most common clinical indications for TG-ERCP were biliary (90%) and pancreatic (10%). The majority of patients underwent an initial laparoscopic approach (90%). Same-day ERCP was successfully achieved in 703 cases (75.5%). Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were 99% (95% CI = 98–100%), 3.1% (95% CI = 1.0–5.8%), 3.4% (95% CI = 1.7–5.5%), and 14.2% (95% CI = 8.5–20.8%), respectively.

Conclusion

TG-ERCP is a safe and effective therapeutic option in patients with symptomatic post-RYGB choledocolithiasis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Ricci C, Gaeta M, Rausa E, et al. Long-term effects of bariatric surgery on type II diabetes, hypertension and hyperlipidemia: a meta-analysis and meta-regression study with 5-year follow-up. Obes Surg. 2015;25(3):397–405.

    Article  Google Scholar 

  2. Rausa E, Bonavina L, Asti E, et al. Rate of death and complications in laparoscopic and open Roux-en-Y gastric bypass. A meta-analysis and meta-regression analysis on 69,494 patients. Obes Surg. 2016;26(8):1956–63.

    Article  Google Scholar 

  3. Gaeta M, Rausa E, Malavazos AE, et al. Bariatric surgery to reduce mortality in US adults. A Public Health Perspective from the Analysis of the American National Health and Nutrition Examination Survey Linked to the US Mortality Register. Obes Surg. 2017.

  4. Ceppa FA, Gagné DJ, Papasavas PK, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007;3(1):21–4.

    Article  Google Scholar 

  5. Byrne TK. Complications of surgery for obesity. Surg Clin North Am. 2001;81(5):1181–93.

    Article  CAS  Google Scholar 

  6. Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg. 2011;98:1345–55.

    Article  CAS  Google Scholar 

  7. Miller K, Hell E, Lang B, et al. Gallstone formation prophylaxis after gastric restrictive procedures for weight loss: a randomized double-blind placebo-controlled trial. Ann Surg. 2003;238:697–702.

    Article  Google Scholar 

  8. Mishra T, Lakshmi KK, Peddi KK. Prevalence of cholelithiasis and choledocholithiasis in morbidly obese south Indian patients and the further development of biliary calculus disease after sleeve gastrectomy, gastric bypass and mini gastric bypass. Obes Surg. 2016;26:2411–7.

    Article  Google Scholar 

  9. Navaratne L, Baltar J, Bustamante M, et al. Treatment of common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg. 2017;27(10):2675–6.

    Article  Google Scholar 

  10. Richardson JF, Lee JG, Smith BR, et al. Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature. Am Surg. 2012;78(10):1182–6.

    Google Scholar 

  11. Banerjee N, Parepally M, Byrne TK, et al. Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis. 2017;13(7):1236–42.

    Article  Google Scholar 

  12. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

    Article  Google Scholar 

  13. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.

    Article  Google Scholar 

  14. Freeman MF, Tukey JW. Transformations related to the angular and the square root. Ann Math Stat. 1950;21(4):607–11.

    Article  Google Scholar 

  15. Miller JJ. The inverse of the Freeman-Tukey double arcsine transformation. Am Stat. 1978;32:138.

    Google Scholar 

  16. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.

    Article  CAS  Google Scholar 

  17. Clopper CJ, Pearson ES. The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika. 1934;6(4):404–13.

    Article  Google Scholar 

  18. Anzures-Cabrera J, Higgins JP. Graphical displays for meta-analysis: an overview with suggestions for practice. Res Synth Methods. 2010;1(1):66–80.

    Article  Google Scholar 

  19. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.

    Article  CAS  Google Scholar 

  20. Borenstein M, Hedges LV, Higgins JPT, et al. Introduction to meta-analysis. Chichester: Wiley; 2009.

    Book  Google Scholar 

  21. Development Core Team R. A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2015. ISBN 3-900051-07-0

    Google Scholar 

  22. Gutierrez JM, Lederer H, Krook JC, et al. Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass. J Gastrointest Surg. 2009;13(12):2170–5.

    Article  Google Scholar 

  23. Lopes TL, Clements RH, Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc. 2009;70(6):1254–9.

    Article  Google Scholar 

  24. Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc. 2011;25(8):2592–6.

    Article  Google Scholar 

  25. Tekola B, Wang AY, Ramanath M, et al. Percutaneous gastrostomy tube placement to perform transgastrostomy endoscopic retrograde cholangiopancreaticography in patients with Roux-en-Y anatomy. Dig Dis Sci. 2011;56(11):3364–9.

    Article  Google Scholar 

  26. Saleem A, Levy MJ, Petersen BT, et al. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg. 2012;16(1):203–8.

    Article  Google Scholar 

  27. Schreiner MA, Chang L, Gluck M, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc. 2012;75(4):748–56.

    Article  Google Scholar 

  28. Choi EK, Chiorean MV, Coté GA, et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc. 2013;27(8):2894–9.

    Article  Google Scholar 

  29. Grimes KL, Maciel VH, Mata W, et al. Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc. 2015;29(7):1753–9.

    Article  Google Scholar 

  30. Snauwaert C, Laukens P, Dillemans B, et al. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients. Endosc Int Open. 2015;3(5):E458–63.

    Article  Google Scholar 

  31. Bowman E, Greenberg J, Garren M, et al. Laparoscopic-assisted ERCP and EUS in patients with prior Roux-en-Y gastric bypass surgery: a dual-center case series experience. Surg Endosc. 2016;30(10):4647–52.

    Article  Google Scholar 

  32. Abbas AM, Strong AT, Diehl DL, et al. Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Gastrointest Endosc. 2017

  33. Frederiksen NA, Tveskov L, Helgstrand F, et al. Treatment of common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg. 2017;27(6):1409–13.

    Article  Google Scholar 

  34. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102(8):1781–8.

    Article  Google Scholar 

  35. Bodger K, Bowering K, Sarkar S, et al. All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death. Gastrointest Endosc. 2011;74(4):825–33.

    Article  Google Scholar 

  36. Abu Dayyeh B. Single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy: getting there. Gastrointest Endosc. 2015;82(1):20–3.

    Article  Google Scholar 

  37. Shah RJ, Smolkin M, Yen R, et al. A multicenter, U.S. experience of single-balloon, doubleballoon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77:593–600.

    Article  Google Scholar 

  38. Saleem A, Baron TH, Gostout CJ, et al. Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy. Endoscopy. 2010;42:656–60.

    Article  CAS  Google Scholar 

  39. Maaser C, Lenze F, Bokemeyer M, et al. Double balloon enteroscopy: a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system. Am J Gastroenterol. 2008;103(4):894–900.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Biomedical Science for Health, Division of General Surgery IRCCS Policlinico San Donato, University of Milan, Piazza Edmondo Malan, 1, 20097, Milan, Italy

    Alberto Aiolfi, Emanuele Asti, Emanuele Rausa, Daniele Bernardi, Gianluca Bonitta & Luigi Bonavina

Authors
  1. Alberto Aiolfi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emanuele Asti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Emanuele Rausa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Daniele Bernardi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Gianluca Bonitta
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Luigi Bonavina
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

A.A, E.R, D.B., and L.B did the literature search.

A.A and L.B. formed the study design.

Data collection was done by A.A, E.R, and D.B.

A.A, G.B. and L.B. analyzed the data.

A.A, E.A., and L.B interpreted the data.

A.A and L.B. wrote the manuscript.

A.A, E.A, and L.B critically reviewed the manuscript.

Corresponding author

Correspondence to Luigi Bonavina.

Ethics declarations

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

Not applicable.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Aiolfi, A., Asti, E., Rausa, E. et al. Trans-Gastric ERCP After Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis. OBES SURG 28, 2836–2843 (2018). https://doi.org/10.1007/s11695-018-3258-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-018-3258-0

Keywords

Search

Navigation