Search Results (6)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) remains technically challenging. Device-assisted ERCP (DAE-ERCP) is widely used for uncomplicated pancreaticobiliary disease but is associated with prolonged procedure times and high failure rates. Endoscopic ultrasound-directed transgastric ERCP (EDGE) offers high technical success but introduces additional cost and the risk of a persistent fistula. We aimed to prospectively identify intra-procedural predictors of DAE-ERCP failure and define an actionable, real-time threshold for early cross-over to EDGE. Methods: We prospectively evaluated consecutive RYGB patients undergoing DAE-ERCP at a tertiary referral center. Patients with established pre-procedural features associated with complex or low-yield DAE-ERCP were triaged directly to EDGE and excluded. Intra-procedural variables were recorded in real time. Univariate and multivariable logistic regression identified predictors of DAE-ERCP failure. Received operating characteristic (ROC) analysis determined optimal cutoffs for cross-over. Results: A total of 94 patients with RYGB underwent ERCP. Amongst these, 42 patients (11 males, 31 females) were included in the analysis and underwent DAE-ERCP with a success rate of 73.8% (n = 31). Significant risk factors of DAE-ERCP failure included excessive resistance to scope advancement (p < 0.0001), failure to reach the ampulla (p < 0.0001), patient position (p = 0.009), BMI (p = 0.004), and time to reach the jejuno-jejunal (J-J) anastomosis (p < 0.0001). Additionally, time needed to reach the J-J anastomosis of ≥23 min [OR 1.360 (95% CI: 1.079–1.713), p = 0.009], excess resistance to scope advancement [OR 2.223 (95% CI: 2.001–4.167)], and failure to reach the ampulla [OR 9.929 (95% CI: 2.004–4.033)] were statistically significant predictors of DAE-ERCP failure. When ≥2 predictors of BA-ERCP failure were present, the likelihood of DAE-ERCP failure was 2.370 with 95.50% sensitivity and 90% specificity with AUC= 0.929 (p = 0.0001). Conclusions: DAE-ERCP remains an effective first-line strategy in appropriately selecting RYGB patients without pre-procedural high-risk features. Real-time intra-procedural predictors can reliably identify impending failure. A structured algorithm incorporating both pre-procedural triage and intra-procedural checkpoints supports timely transition to EDGE, optimizing efficiency, safety, and resource utilization. Full article

Background: The rising prevalence of gastric, biliary, and pancreatic surgeries has led to an increasing population of patients with surgically altered anatomy (SAA). In this setting, conventional endoscopic retrograde cholangiopancreatography (ERCP) is often limited by anatomical barriers, resulting in high rates of technical failure and complications. While device-assisted enteroscopy (DAE) has expanded therapeutic possibilities, its efficacy remains modest in complex reconstructions. Methods: This review analyzed recent literature from PubMed, Embase, and Scopus up to April 2025, focusing on diagnostic and therapeutic roles of endoscopic ultrasound (EUS) in SAA. Particular attention was given to cases where standard endoscopic, percutaneous, or surgical techniques failed and to studies comparing EUS-guided approaches with alternative modalities. Results: EUS has transitioned from a primarily diagnostic modality to a versatile therapeutic platform in SAA. Techniques such as EUS-guided rendezvous, antegrade drainage, and hepaticogastrostomy have shown technical and clinical success rates exceeding 80–90%, often comparable or superior to interventional radiology, while reducing the need for external drains. Innovative procedures, including EUS-directed transgastric ERCP (EDGE) and EUS-directed enteroenteric bypass (EDEE), have transformed the management of Roux-en-Y gastric bypass and bilioenteric anastomoses, providing durable and reusable access for repeated interventions. Despite these advances, EUS-guided interventions remain technically demanding, requiring advanced endoscopic and radiologic skills, specialized devices, and are best performed in tertiary referral centers. Conclusions: EUS has redefined the treatment paradigm of biliopancreatic diseases in patients with SAA, increasingly emerging as the preferred minimally invasive approach when conventional techniques fail. Future developments will focus on dedicated devices, standardized guidelines, and structured training programs to optimize outcomes. Multidisciplinary collaboration and centralization in high-volume centers remain essential to ensure safety, efficacy, and reproducibility. Full article

Patients with Roux-en-Y gastric bypass (RYGB) are a significant challenge for endoscopic retrograde cholangiopancreatography (ERCP) due to the altered anatomy. Endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) has emerged as a valuable alternative to standard methods like enteroscopy-assisted (EA-ERCP) and laparoscopy-assisted (LA-ERCP) ERCP. EDGE involves creating a temporary fistula between the gastric pouch and the excluded stomach under EUS guidance, typically using a lumen-apposing metal stent (LAMS). This allows a standard ERCP scope to access the second duodenum and the biliary tree with standard devices. Several studies have investigated the efficacy and safety of this approach, with variations in techniques such as suturing the LAMS to prevent migration. EDGE has demonstrated high technical success rates, and current evidence indicates that it can be performed safely, with acceptable rates of adverse events such as stent migration, bleeding, and perforation, making it the preferred option in referral centers. This comprehensive review aims to provide a concise evaluation of EDGE, its techniques, outcomes, and role in managing biliary and pancreatic disorders in RYGB patients. Full article

Technological advances have greatly expanded the diagnostic and therapeutic capabilities of endoscopic ultrasound (EUS). The integration of cutting-edge imaging techniques, including tissue harmonic echo, contrast-enhanced harmonic EUS, elastography, and needle-based confocal laser endomicroscopy, have significantly enhanced lesion characterization and diagnostic accuracy. Additionally, developments in stent design and the introduction of new accessories have broadened the therapeutic applications of EUS. Ongoing innovations in clinical practice have transformed procedures such as drainage, tumor ablation, EUS-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), the placement of fiducial markers, advancements in endohepatology, lesion characterization, and treatment. These developments continue to expand the role of EUS in delivering precise and effective therapeutic interventions. Full article

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the preferred method for managing biliary obstructions. However, the prevalence of surgically modified anatomies often poses challenges, making the standard side-viewing duodenoscope unable to reach the papilla in most cases. The increasing instances of surgically altered anatomies (SAAs) result from higher rates of bariatric procedures and surgical interventions for pancreatic malignancies. Conventional ERCP with a side-viewing endoscope remains effective when there is continuity between the stomach and duodenum. Nonetheless, percutaneous transhepatic biliary drainage (PTBD) or surgery has historically been used as an alternative for biliary drainage in malignant or benign conditions. The evolving landscape has seen various endoscopic approaches tailored to anatomical variations. Innovative methodologies such as cap-assisted forward-viewing endoscopy and enteroscopy have enabled the performance of ERCP. Despite their utilization, procedural complexities, prolonged durations, and accessibility challenges have emerged. As a result, there is a growing interest in novel enteroscopy and endoscopic ultrasound (EUS) techniques to ensure the overall success of endoscopic biliary drainage. Notably, EUS has revolutionized this domain, particularly through several techniques detailed in the review. The rendezvous approach has been pivotal in this field. The antegrade approach, involving biliary tree puncturing, allows for the validation and treatment of strictures in an antegrade fashion. The EUS-transmural approach involves connecting a tract of the biliary system with the GI tract lumen. Moreover, the EUS-directed transgastric ERCP (EDGE) procedure, combining EUS and ERCP, presents a promising solution after gastric bypass. These advancements hold promise for expanding the horizons of comprehensive and successful biliary drainage interventions, laying the groundwork for further advancements in endoscopic procedures. Full article

Background and Objectives: Anatomical post-surgical alterations of the upper gastrointestinal (GI) tract have always been challenging for performing diagnostic and therapeutic endoscopy, especially when biliopancreatic diseases are involved. Esophagectomy, gastrectomy with various reconstructions and pancreaticoduodenectomy are among the most common surgeries causing upper GI tract alterations. Technological improvements and new methods have increased the endoscopic success rate in these patients, and the literature has been rapidly increasing over the past few years. The aim of this systematic review is to identify evidence on the available biliopancreatic endoscopic techniques performed in the altered post-surgical anatomy of upper GI tract. Materials and Methods: We performed a systematic search of PubMed, MEDLINE, Cochrane Library, and SCOPUS databases. Study-level variables extracted were the last name of the first author, publication year, study design, number of patients, type of post-surgical anatomical alteration, endoscopic technique, success rate and endoscopic-related adverse events. Results: Our primary search identified 221 titles, which was expanded with studies after the citation search. The final full-text review process identified 52 articles (31 retrospective studies, 8 prospective studies and 13 case reports). We found several different techniques developed over the years for biliopancreatic diseases in altered anatomy, in order to perform both endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). They included enteroscopy-assisted ERCP (double and single balloon enteroscopy-ERCP, spiral enteroscopy-ERCP) laparoscopic assisted ERCP, EUS-Directed transgastric ERCP, EUS-directed transgastric intervention, gastric access temporary for endoscopy, and percutaneous assisted trans prosthetic endoscopic therapy. The success rate was high (most of the techniques showed a success rate over 90%) and a low rate of adverse events were reported. Conclusions: We suggest the considerationof the novel techniques when approaching patients with altered anatomy who require biliopancreatic endoscopy, focusing on the surgery type, success rate and adverse events reported in the literature. Full article