title: Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique.
abstract: BACKGROUND
  Patients with Roux-en-Y gastric bypass (RYGB) anatomy pose challenges when endoscopic retrograde cholangiopancreatography (ERCP) is required. Deep enteroscopy-assisted ERCP can allow pancreaticobiliary intervention in these patients, but with limited success. This case series describes endoscopic ultrasound-directed transgastric ERCP (EDGE) for patients following RYGB.
  
  
  METHODS
  Patients with RYGB anatomy undergoing EDGE at a tertiary care center were included in this prospective single-arm feasibility study. All procedures were performed in two stages. First a 16-Fr percutaneous endoscopic gastrostomy (PEG) was placed in the excluded stomach using endoscopic ultrasound (EUS) guidance. Second, ERCP was performed through the newly fashioned gastrostomy and a transcutaneous fully covered metal esophageal stent.
  
  
  RESULTS
  Six patients (5 women, 1 man) with RYGB anatomy underwent EDGE. EUS-guided PEG placement was successful in all six patients (100 %). Antegrade ERCP was successful in all six patients (100 %) with the stages being separated by a mean of 5.8 days. The mean procedure times for the two stages were 81 minutes and 98 minutes. Two patients (33 %) had localized PEG site infections that were managed with oral antibiotics. There were no adverse events related to ERCP.
  
  
  CONCLUSIONS
  EDGE is both feasible and safe to perform in RYGB patients. Given the high success rates of our recent experience, we suspect that this technique can be performed as a one-stage procedure to provide a cost-effective, minimally invasive option for a common problem in a growing patient population.
authors.affiliation: Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA.
authors.forename: Prashant
authors.initials: P
authors.lastname: Kedia
authors.affiliation: Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA.
authors.forename: Nikhil A
authors.initials: NA
authors.lastname: Kumta
authors.affiliation: Division of Gastroenterology, North Shore-LIJ, Forest Hills Hospital, New York, USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Widmer
authors.affiliation: Red Bank Gastroenterology, Riverview Medical Center, New Jersey, USA.
authors.forename: Subha
authors.initials: S
authors.lastname: Sundararajan
authors.affiliation: Division of Gastroenterology, Jersey Shore University Medical Center, New Jersey, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Cerefice
authors.affiliation: Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA.
authors.forename: Monica
authors.initials: M
authors.lastname: Gaidhane
authors.affiliation: Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA.
authors.forename: Reem
authors.initials: R
authors.lastname: Sharaiha
authors.affiliation: Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA.
authors.forename: Michel
authors.initials: M
authors.lastname: Kahaleh
mesh_terms: D000328:Adult; D000368:Aged; D000713:Anastomosis, Roux-en-Y; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D002779:Cholestasis / Q000601:surgery; D019160:Endosonography; D005240:Feasibility Studies; D005260:Female; D015390:Gastric Bypass; D005774:Gastrostomy / Q000009:adverse effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011446:Prospective Studies; D015607:Stents; D013530:Surgical Wound Infection / Q000209:etiology*