Authors: Yeshaswini Reddy, Srinivas R Puli, David Forcione.
Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass patients is very challenging. Access to the excluded stomach or jejunum using Endoscopic Ultrasound (EUS) guided Lumen- Apposing Metal Stents (LAMS) and performing ERCP is becoming more available.
Methods: We conducted a systematic review and meta-analysis with two authors independently reviewing electronic databases (PubMed, Embrace, and Cochrane Library) from inception through June 2022. Fixed and random effects models were used to calculate the weighted mean (WM), pooled proportions, and confidence intervals (CI).
Results: On initial search, 457 articles were found, of which 63 were selected and reviewed. Data was extracted from 11 studies (n= 543) examining EDGE procedure in Roux-en-Y gastric bypass patients. The primary outcome was successful LAMS placement with a pooled rate of 97.84% (95% CI = 96.46 to 98.89). Successful ERCP through the LAMS was calculated as the secondary outcome. This gave a pooled proportion of 95.57% (95% CI = 93.11 to 97.51). The pooled proportion of patients who underwent ERCP in one session was 46.89 % (95% CI = 42.59 to 51.22), and in two different sessions was 53.45 % (95% CI = 49.13 to 57.75). This pooled analysis noted a persistent fistula after stent removal in 14.02 % of patients (95% CI =11.12 to 17.18). Procedure-related complications such as stent migration were reported in 7.72% of patients (95% CI = 5.63 to 10.09), and perforation was seen in 4.33 % of patients (95% CI= 2.67 to 6.36). The pooled analysis of other complications included bleeding that was seen in 1.83 % of patients (95% CI = 0.79 to 3.27), post-ERCP pancreatitis in 2.43 % of patients (95% CI = 1.18 to 4.11), and infection in 1.04 % of patients (95% CI = 0.27 to 2.27). The pooled estimates calculated with fixed and random effects models were the same. Publication bias calculated using the Harbord-Egger bias indicator gave a value of 2.60 (p =0.16). The Begg-Mazumdar indicator gave Kendall's tau b value of 0.07 (p = 0.90).
Conclusions: EDGE is a minimally invasive procedure with a high technical success rate in patients requiring biliary intervention after Roux-en-Y gastric bypass. There are minimal intra and post-procedural complications. So, EDGE can be used as the first-line therapy in this patient population.
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