EUS-Directed Transgastric ERCP (EDGE Procedure) for Management of Choledocholithiasis in Post-Gastric Bypass Anatomy
The current management of biliary pancreatitis or choledocholithiasis consists of prompt decompression of the common bile duct. However, the Roux-en-Y gastric bypass anatomy poses a challenge for retrograde cholangiopancreatography (ERCP) due to the divided stomach. The EUS-directed transgastric ERCP (EDGE) procedure represents a minimally invasive, effective, and feasible method to access the biliary tree in post-gastric bypass anatomy, offering an appealing alternative treatment option besides laparoscopy- or deep-enteroscopy-assisted ERCP. While preliminary data has demonstrated excellent technical and clinical success rates, the concern for persistent gastrogastric fistula remains. In addition, high operator endoscopy expertise and rescue options for the small chance of stent dislodgement during or after procedure must be readily available before embarking on the learning curve. It is paramount that a multidisciplinary approach involving both bariatric surgery and gastroenterology expertise be taken when making decisions to pursue an EDGE procedure.
