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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class="h4">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.

class="h4">Objective

To determine the feasibility of transgastric endoscopy and ERCP through a newly created PEG augmented by SEMS placement.

class="h4">Design

Prospective live animal study; human case report.

class="h4">Settings

Animal laboratory and endoscopy units, tertiary care medical center.

class="h4">Subjects

Nine domestic pigs; 1 patient.

class="h4">Interventions

PEG tract with SEMS placement; transgastric endoscopy through SEMS.

class="h4">Main Outcome Measurements

Technical success, feasibility of transgastric endoscopy.

class="h4">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.

class="h4">Limitations

Small number of subjects.

class="h4">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.