Transenteric endoscopic retrograde cholangiopancreatography via endoscopic ultrasound–guided anastomosis using lumen-apposing metal stents in patients with surgically altered anatomy (with video)

Background and Aims Endoscopic ultrasonography (EUS)-directed transenteric endoscopic retrograde cholangiopancreatography (ERCP) (EUS-directed transenteric ERCP [EDEE]) using a lumen-apposing metal stent (LAMS) is a novel biliary drainage technique for patients with surgically altered anatomy. The study aimed to evaluate the feasibility, safety, and effectiveness of EDEE. Methods This is 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 (AEs). 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. Conclusions 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.