Post written by Majidah Bukhari, MBBS, MD, FRCPC, from the Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA, and King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

Roux-en-Y gastric bypass (RYGB) remains one of the most commonly performed bariatric surgeries worldwide. ERCP in patients with RYGB anatomy poses particular challenges to interventional endoscopists. Enteroscopy-assisted ERCP (e-ERCP) has improved the ability to reach the native papilla in patients with RYGB. Yet, it is fraught with significant challenges even when performed by expert interventional endoscopists. Thus, various alternative techniques have been described to overcome these challenges by allowing direct access to the excluded stomach in order to facilitate conventional ERCP in those patients.

EUS-guided gastrogastrostomy-assisted ERCP (EUS-GG-ERCP) is a novel and minimally invasive technique to gain access to the excluded stomach in order to facilitate conventional ERCP by a single provider. In addition, it is an optimal technique for patients with multiple abdominal surgeries in which laparoscopic-assisted ERCP may be deemed high risk. While EUS-GG-ERCP offers multiple potential advantages in patients with RYBG, it is currently unknown how such an approach compares to e-ERCP in practice. The focus of our study was to compare EUS-GG-ERCP and e-ERCP directly; we excluded patients who underwent EUS-GG-ERCP after a previously failed e-ERCP to avoid skewing observations of technical success.

This is the first international multi-center trial to compare EUS-GG-ERCP and e-ERCP in patients with RYGB. Our study demonstrates that ERCP success rate is significantly higher in patients who underwent EUS-GG compared to those that underwent e-ERCP. This study also demonstrates that a single-session EUS-GG-ERCP procedure is a feasible and  potentially effective therapeutic approach in patients who needed emergency biliary decompression. EUS-GG-ERCP is a technically challenging procedure and requires expertise in interventional EUS and ERCP. These results may not apply to community practice. To validate these results, large prospective randomized clinical trials are recommended to better understand its efficacy and safety profile.

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