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)

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• 作者：Todd H. Baron ; MD¹ ; ; Louis M. Wong Kee Song ; MD¹ ; Lincoln E.V.V. Ferreira ; MD³ ; Thomas C. Smyrk ; MD²
• 关键词：BAE ; balloon-assisted enteroscopy ; DBE ; double-balloon enteroscopy ; PEG ; percutaneous endoscopic gastrostomy ; RPEG ; retrograde percutaneous endoscopic gastrostomy ; RYGB ; Roux-en-Y gastric bypass ; SEMS ; self-expandable metal stent
• 刊名：Gastrointestinal Endoscopy
• 出版年：2012
• 期刊代码：130_00165107
• 类别：med
• 出版时间：June, 2012
• 卷：75
• 期：6
• 页码：1258-1263
• 文件大小：1665 K

摘要

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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.