Novel approach to therapeutic ERCP after long-limb Roux-en-Y gastric bypass surgery using transgastric self-expandable metal stents: Experimental outcomes and first human case study (with videos)

Todd H. Baron, Louis M Wong Kee Song, Lincoln E V V Ferreira, Thomas Christopher Smyrk

Research output: Contribution to journalArticle

20 Citations (Scopus)

Abstract

Background: ERCP in Roux-en-Y gastric bypass (RYGB) patients is challenging. Balloon-assisted enteroscopy (BAE) allows access to the excluded stomach with creation of a percutaneous endoscopic gastrostomy (PEG). Transgastric self-expandable metal stent (SEMS) placement may allow antegrade ERCP in 1 session. Objective: To determine the feasibility of transgastric endoscopy and ERCP through a newly created PEG augmented by SEMS placement. Design: Prospective live animal study; human case report. Settings: Animal laboratory and endoscopy units, tertiary care medical center. Subjects: Nine domestic pigs; 1 patient. Interventions: PEG tract with SEMS placement; transgastric endoscopy through SEMS. Main Outcome Measurements: Technical success, feasibility of transgastric endoscopy. Results: Successful SEMS deployment was achieved in 9 of 9 animals. The stent was removed in 6 animals; 3 were killed within 24 hours (group A) and 3 were killed 1 week later (group B). In 3 animals, stents remained in place, they were killed 9 to 15 days later (group C). Duodenoscopy was difficult in 1 animal from group A resulting in stent dislodgment. Peristomal infection occurred in 1 animal in group B. In group C, 1 stent was buried subcutaneously and 1 completely migrated out. Necropsy showed no peritoneal fluid or peritonitis in any animal. In the 1 patient, BAE-assisted PEG and SEMS placement in the excluded stomach allowed antegrade ERCP and biliary sphincterotomy without adverse events. Limitations: Small number of subjects. Conclusions: Performance of PEG with immediate SEMS placement allows for antegrade transgastric ERCP during 1 procedure. With the use of BAE, retrograde PEG/SEMS in excluded stomach allows therapeutic ERCP without need for surgery.

Original languageEnglish (US)
Pages (from-to)1258-1263
Number of pages6
JournalGastrointestinal Endoscopy
Volume75
Issue number6
DOIs
StatePublished - Jun 2012

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Gastric Bypass
Endoscopic Retrograde Cholangiopancreatography
Gastrostomy
Extremities
Endoscopy
Stents
Stomach
Therapeutics
Duodenoscopy
Sus scrofa
Self Expandable Metallic Stents
Ascitic Fluid
Laboratory Animals
Peritonitis
Tertiary Care Centers
Infection

Keywords

  • BAE
  • balloon-assisted enteroscopy
  • DBE
  • double-balloon enteroscopy
  • PEG
  • percutaneous endoscopic gastrostomy
  • retrograde percutaneous endoscopic gastrostomy
  • Roux-en-Y gastric bypass
  • RPEG
  • RYGB
  • self-expandable metal stent
  • SEMS

ASJC Scopus subject areas

  • Gastroenterology
  • Radiology Nuclear Medicine and imaging

Cite this

Novel approach to therapeutic ERCP after long-limb Roux-en-Y gastric bypass surgery using transgastric self-expandable metal stents : Experimental outcomes and first human case study (with videos). / Baron, Todd H.; Song, Louis M Wong Kee; Ferreira, Lincoln E V V; Smyrk, Thomas Christopher.

In: Gastrointestinal Endoscopy, Vol. 75, No. 6, 06.2012, p. 1258-1263.

Research output: Contribution to journalArticle

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abstract = "Background: ERCP in Roux-en-Y gastric bypass (RYGB) patients is challenging. Balloon-assisted enteroscopy (BAE) allows access to the excluded stomach with creation of a percutaneous endoscopic gastrostomy (PEG). Transgastric self-expandable metal stent (SEMS) placement may allow antegrade ERCP in 1 session. Objective: To determine the feasibility of transgastric endoscopy and ERCP through a newly created PEG augmented by SEMS placement. Design: Prospective live animal study; human case report. Settings: Animal laboratory and endoscopy units, tertiary care medical center. Subjects: Nine domestic pigs; 1 patient. Interventions: PEG tract with SEMS placement; transgastric endoscopy through SEMS. Main Outcome Measurements: Technical success, feasibility of transgastric endoscopy. Results: Successful SEMS deployment was achieved in 9 of 9 animals. The stent was removed in 6 animals; 3 were killed within 24 hours (group A) and 3 were killed 1 week later (group B). In 3 animals, stents remained in place, they were killed 9 to 15 days later (group C). Duodenoscopy was difficult in 1 animal from group A resulting in stent dislodgment. Peristomal infection occurred in 1 animal in group B. In group C, 1 stent was buried subcutaneously and 1 completely migrated out. Necropsy showed no peritoneal fluid or peritonitis in any animal. In the 1 patient, BAE-assisted PEG and SEMS placement in the excluded stomach allowed antegrade ERCP and biliary sphincterotomy without adverse events. Limitations: Small number of subjects. Conclusions: Performance of PEG with immediate SEMS placement allows for antegrade transgastric ERCP during 1 procedure. With the use of BAE, retrograde PEG/SEMS in excluded stomach allows therapeutic ERCP without need for surgery.",
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AU - Song, Louis M Wong Kee

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AU - Smyrk, Thomas Christopher

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AB - Background: ERCP in Roux-en-Y gastric bypass (RYGB) patients is challenging. Balloon-assisted enteroscopy (BAE) allows access to the excluded stomach with creation of a percutaneous endoscopic gastrostomy (PEG). Transgastric self-expandable metal stent (SEMS) placement may allow antegrade ERCP in 1 session. Objective: To determine the feasibility of transgastric endoscopy and ERCP through a newly created PEG augmented by SEMS placement. Design: Prospective live animal study; human case report. Settings: Animal laboratory and endoscopy units, tertiary care medical center. Subjects: Nine domestic pigs; 1 patient. Interventions: PEG tract with SEMS placement; transgastric endoscopy through SEMS. Main Outcome Measurements: Technical success, feasibility of transgastric endoscopy. Results: Successful SEMS deployment was achieved in 9 of 9 animals. The stent was removed in 6 animals; 3 were killed within 24 hours (group A) and 3 were killed 1 week later (group B). In 3 animals, stents remained in place, they were killed 9 to 15 days later (group C). Duodenoscopy was difficult in 1 animal from group A resulting in stent dislodgment. Peristomal infection occurred in 1 animal in group B. In group C, 1 stent was buried subcutaneously and 1 completely migrated out. Necropsy showed no peritoneal fluid or peritonitis in any animal. In the 1 patient, BAE-assisted PEG and SEMS placement in the excluded stomach allowed antegrade ERCP and biliary sphincterotomy without adverse events. Limitations: Small number of subjects. Conclusions: Performance of PEG with immediate SEMS placement allows for antegrade transgastric ERCP during 1 procedure. With the use of BAE, retrograde PEG/SEMS in excluded stomach allows therapeutic ERCP without need for surgery.

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