Transenteric ERCP via EUS-guided anastomosis using LAMS in patients with surgically altered anatomy.

Background and study aims: Endoscopic ultrasound (EUS)-directed transenteric endoscopic retrograde cholangiography (ERCP, EDEE) using a lumen-apposing metal stent (LAMS) is a novel biliary drainage technique for patients with surgically altered anatomy. To evaluate the feasibility, safety and effectiveness of EDEE.

Patients and methods: A multicenter, retrospective study. We included consecutive patients with altered anatomy who underwent an EDEE. Surgical anatomy configuration, prior biliary drainage and ERCP indications were collected. The EUS-guided anastomosis technique was assessed. The primary outcome was the technical success of the EDEE. The secondary outcomes were the clinical success and the adverse events (AE).

Results: Ninety-four ERCPs were performed in 55 patients (60±16.2 years-old, 56.4% male). The most frequent surgical anatomy was Roux-en-Y hepaticojejunostomy (n=23, 41.8%) and a prior biliary drainage was performed in 28 patients (50.9%). Benign strictures were the most frequent indication (58.2%). The most frequent techniques to identify the biliary limb were EUS imaging alone (n=14, 25.5%) and EUS-guided puncture of the biliary limb with retrograde opacification of the surgical hepaticojejunostomy (n=14, 25.5%). The procedure was performed using a direct freehand approach (n=49, 89.1%). Technical and clinical success rates of EDEE were 87.3% and 93.8%, respectively. The overall AE rate was 20% (9.1% LAMS-related). The rate of persistent fistula was 30.6% with a median follow-up period of 3 months.

Conclusion: The EDEE technique offers a new and effective approach for biliary drainage in patients with surgically altered anatomy, particularly in benign indications and/or when several ERCPs are expected.