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WEIGHT MATTERS: LONG-TERM EVALUATION OF WEIGHT REGAIN AND FISTULA RECURRENCE POST ENDOSCOPIC ULTRASOUND-DIRECTED TRANSGASTRIC ERCP
Yervant Ichkhanian
*, Adel Hajj Ali, Jeffrey J. Easler, Itegbemie Obaitan, James L. Watkins, Evan L. Fogel, Nasir Saleem, John M. Dewitt, Mohammad A. Al-Haddad, Mark A. Gromski, Sujani Yadlapati
Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
Background: Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE) is a technique that aids in performing ERCP in patients with Roux-en-Y gastric bypass (RYGB); however, persistent fistula and weight regain continue to be a concern. We reported our long-term, ?3.5 years, post-EDGE outcomes on the effectiveness of fistula closure techniques, risk of recurrence, and weight gain.
Methods: Retrospective review of a prospectively maintained database of patients who underwent EDGE from 9/2017 to 11/2020. Patients underwent EUS-gastrogastrostomy (EUS-GG) or jejunogastrostomy (EUS-JG) for ERCP access. The presence or absence of a fistula was confirmed radiographically or endoscopically.
Results: A total of 34 patients (mean age 68 ± 9.21 years, 79% F) underwent EDGE a median of 10.3 years (IQR 5-13.5) post-RYGB. The targeted interventions of the EDGE were biliary in 27 (79%), and pancreatic in 7 (21%) patients. At presentation, 4 (12%) patients had cholangitis. EUS-guided lumen-apposing metal stent (LAMS) [15-mm, 28 (82%), 20-mm, 6 (18%)] deployment was technically successful in all patients. Stent dilation was performed in 14 (41%), and anchored in 8 (34%) patients. ERCP was performed concurrently in 5 (15%) cases [cholangitis (4), pancreatic duct stone (1)], while the remaining patients underwent ERCP at a median time of 8.5 (IQR 7-14) days post EUS-GG/JG. ERCP technical failure due to LAMS migration occurred in 2 (6.3%) cases, necessitating endoscopic removal and fistula closure. Median indwelling time of LAMS was 40 (IQR 30-45) days, with endoscopic closure performed in 30 (88%) patients. One severe adverse event involved a de novo surgical gastrointestinal junction ulcer post EUS-GG which progressed to stenosis requiring surgical intervention. Early fistula closure was confirmed in 30 (88%) patients at a median time of 1.6 (IQR 1.3-3.5) months post-LAMS removal, and absence of fistula recurrence was confirmed in 18 (53%) patients at a median time of 3.7 years (IQR 3.5-4.4) post-LAMS removal. Spontaneous fistula closure was confirmed in 3 (75%) out of the 4 patients who did not undergo endoscopic fistula closure
(Table 1). Weight analysis revealed a median delta weight change of -1.5 kg (IQR 1-4) during LAMS indwelling, while 20 (59%) of patients experienced weight gain, +3 kg (IQR 2.4-3.2). Long-term, up-to 4-years, follow-up showed a median delta weight change of +0.65 kg (IQR 0.3-1) with 16 (47%) experiencing weight gain, +4.15 kg (IQR 3.4-5.2). No significant differences in weight changes were found between patients with and without endoscopic fistula closure or among the different fistula closure techniques
(Figure 1).
Conclusion: Patients post EDGE experienced long-term weight stability and there were no reported cases of spontaneous fistula recurrence, thus demonstrating the safety of the EDGE technique in this patient population.
Table 1. Baseline patient and procedure characteristics of patients who underwent endoscopic retrograde cholangiopancreatography
Figure 1. Weight change depending on the fistula closure method
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