EUS-Directed Transgastric ERCP: Systematic Review to Describe outcomes, adverse events and knowledge gaps.

Background and Aims: EUS-directed transgastric ERCP (EDGE) has emerged as a viable, completely endoscopic method for performing pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. The aims of this systematic review are: 1) to describe indications, outcomes and complications of EDGE; and 2) to identify deficiencies in our knowledge of important technical approaches and clinical outcomes. Patients and methods: A systematic review was conducted via comprehensive search of MEDLINE, SCOPUS, CINAHL, and Cochrane to identify studies focused on EDGE outcomes. Simple descriptive statistics were derived from case series only. Case reports were only included to qualitatively describe additional indications, techniques, and adverse events (AE). Results: The initial search identified 2143 abstracts. Nine case series and eight case reports were included. In the nine case series, 169 patients underwent EDGE. Technical success was 99% (168/169) for gastrogastrostomy/jejunogastrostomy creation and 98% (166/169) for subsequent ERCP. Minor AE specifically related to EDGE occurred in 18% (31/169) and included intraprocedural stent migration/malposition (n=27) and abdominal pain (n=4). Moderate AE specific to EDGE occurred in 5% (9/169) and included: bleeding (2%); persistent fistula (1%); and perforation (1%). Severe AE occurred in one patient due to perforation requiring surgery. Deficiency in reporting on clinical significance of AE’s was identified. Conclusion: Based on limited observational data, in expert hands EDGE has a high rate of technical success and an acceptable rate of AE’s. As a novel procedure, many knowledge gaps need to be addressed to inform the design of meaningful comparative studies and guide informed consent.