Understanding the Role of Different ERCP Techniques in Post-Roux-en-Y Gastric Bypass Patients: a Systematic Review and Meta-analysis

Bálint Gellért; Anett Rancz; Jakub Hoferica; Brigitta Teutsch; Zoltán Sipos; Dániel S Veres; Péter Jenő Hegyi; Szabolcs Ábrahám; Péter Hegyi; István Hritz

doi:10.1007/s11695-024-07459-z

. 2024 Dec 13;35(1):285–304. doi: 10.1007/s11695-024-07459-z

Understanding the Role of Different ERCP Techniques in Post-Roux-en-Y Gastric Bypass Patients: a Systematic Review and Meta-analysis

Bálint Gellért ^1,², Anett Rancz ^1,³, Jakub Hoferica ^1,⁴, Brigitta Teutsch ^1,^5,⁶, Zoltán Sipos ^5,⁷, Dániel S Veres ⁸, Péter Jenő Hegyi ^1,⁹, Szabolcs Ábrahám ¹⁰, Péter Hegyi ^1,^5,^9,¹¹, István Hritz ^2,^✉

PMCID: PMC11717856 PMID: 39671059

Abstract

We aimed to compare enteroscopy-assisted ERCP (EA-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and endoscopic ultrasound-directed ERCP (EDGE) in terms of safety and efficacy in post-Roux-en-Y gastric bypass patients. We conducted a rigorous analysis based on a predefined protocol (PROSPERO, CRD42022368788). Sixty-seven studies were included. The technical success rates were 77% (CI 69–83%) for EA-ERCP, 93% (CI 91–96%) for LA-ERCP, and 96% (CI 92–98%) for EDGE. Subgroup differences were significant between the EA-ERCP and other groups (p < 0.05). The overall adverse event rates were 13% (CI 8–22%), 19% (CI 14–24%), and 20% (CI 12–31%), respectively (p = 0.49). Our findings suggest that EDGE and LA-ERCP may be more effective and as safe as EA-ERCP.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-024-07459-z.

Keywords: ERCP, Surgically altered anatomy, Laparoscopy, Enteroscopy, Endoscopic ultrasound

Introduction

The ever-growing burden of the obesity pandemic has increased the number of bariatric surgeries performed. An epidemiological survey showed that almost 49,000 Roux-en-Y gastric bypass (RYGB) operations were performed in 26 European countries in 2018, making it the second most common bariatric surgery type [1]. A patient with an RYGB anatomy admitted for pancreaticobiliary intervention raises difficult questions for endoscopists regarding the access routes to the papilla of Vater.

Endoscopic retrograde cholangiopancreatography (ERCP) is often required in these patients, primarily because of the high incidence of gallstone formation after rapid weight loss, but other indications are also common. The two current gold standard ERCP techniques are enteroscopy-assisted ERCP (EA-ERCP) [2] and laparoscopy-assisted ERCP (LA-ERCP) [3, 4], and the most recent one is endoscopic ultrasound-directed transgastric ERCP (EDGE) [5, 6]. Because the three modalities require different technical skills, expertise, and technological backgrounds, research has been conducted to determine the advantages and disadvantages of each procedure. Recent data suggest that EDGE and LA-ERCP appear more effective but less safe than EA-ERCP [7–12]. Cost-effectiveness and cost-utility analyses found EDGE the best option, and LA-ERCP was the costliest [13, 14]. This controversy has created a dilemma in therapeutic decision-making.

The current study aimed to address this issue by conducting a systematic review and meta-analysis to investigate the safety and efficacy of EA-ERCP, LA-ERCP, and EDGE in patients who previously underwent RYGB.

Materials and Methods

This study was performed according to a predetermined protocol registered on the PROSPERO website (CRD42022368788), and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to design and conduct the study.

Eligibility Criteria

The PICO framework was used to address the questions posed in this systematic review. Studies reporting consecutive patients with RYGB anatomy (P) undergoing EDGE and/or LA-ERCP and/or EA-ERCP (I/C) and reporting technical and clinical success and/or complications (O) were included. Both interventional and observational studies were eligible for inclusion. Comparative (multi-arm) and non-comparative (one-arm) studies were also included. Case reports and congress abstracts were excluded from the study. Detailed information on the inclusion criteria is provided in Sect. "Eligibility Criteria" of Supplementum.

Systematic Search

A comprehensive search was conducted in three databases: MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) Library on November 20, 2022. A backward and forward reference search of eligible studies was performed on January 12, 2023, using The Lens citation chaser tool. More information on the systematic search and detailed search key can be found in Document 1 of Supplementum.

Selection Process

Information on the selection process is available in Supplementum, Sect. "Selection Process".

Data Collection

A description of the data collection process can be found in Supplementum, Sect. "Data Collection".

Data Items

A description of the collected data item can be found in Supplementum, Sect. "DataItems".

Outcomes

Primary outcomes included technical success rate and clinical success rate.

The secondary outcomes were the number of overall (pooled) and individual adverse events. More information on the outcomes can be found in Supplementum, Sect. "Outcomes".

Effect Measures

Proportions with a 95% confidence interval (CI) for indirect comparisons and odds ratios (OR) with 95% CI for direct comparisons were used for the effect size measure. Detailed information on the effect measures is provided in Supplementum, Sect. "Effect Measures".

Synthesis Methods

For a detailed description of the statistical synthesis methods, see Supplementum, Sect. "Synthesis Methods".

Risk of bias (RoB)

The RoB evaluation was performed independently by two reviewers (B.G. and J.H.). Disagreements were resolved by a third independent reviewer (A.R.). The Risk of Bias in Non-randomized Studies (ROBINS-I) tool was used for the observational interventional studies. RoB for non-comparative studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. In this review, a MINORS score ≤ 8 was considered high risk, 9–14 moderate risk, and 15–16 low risk of bias. The RoB assessment tools are described in Supplementum, Sect. "Risk of bias (RoB)".

Certainty Assessment

Quality of evidence (QoE) was assessed using the GRADE tool. Two reviewers (B.G. and J.H.) conducted the GRADE assessment independently. Disagreements were resolved by a third independent reviewer (A.R.). The GRADE tool is described in the Supplementum, Sect. "Certainty Assessment".

Results

Search and Selection

Altogether, 8882 hits were found after duplicate removal, and 2714 patients from 67 studies were included in the review (Fig. 1).

Baseline Characteristics

The baseline characteristics of the included studies are shown in Table 1. Of these, 62 were retrospective, and 5 were prospective in design. Seven studies compared two different interventions. A total of 35 studies reported on LA-ERCP, 13 on EDGE, and 12 on EA-ERCP alone.

Table 1.

Baseline characteristics of included studies

Number	Author, year	Study design	Study period, country	Age (years)¹	Sex (female% of total)	Indications (for every ERCP procedures of interest if it is possible, if not than for the whole study)
Number	Author, year	Study design	Study period, country	Age (years)¹	Sex (female% of total)	CDL (n)	Cholangitis (n)	Malignant stenosis (n)	Benign stenosis (n)	Undefined biliary stricture/obstruction (n)	Acute pancreatitis (n)	SOD/papillary stenosis (n)	Abnormal LFTs/abnormal imaging (n)	Bile leak (n)	Other (n)
Studies about EDGE
1	Chhabra, 2022	retrospective single-arm interventional	January 2020–October 2021, UK	65.8 ± 9.8	85.7	13	0	0	0	0	0	1	0	1	0
2	Tyberg, 2020**	retrospective single-arm interventional	over 3 years, not specified, USA	58.7 ± 10.6	79	5	0	0	0	6	3	0	0	0	5
3	Krafft, 2021	Retrospective cohort	March 2018–February 2020, USA	SS-EDGE: 54.9 ± 11.9; DS-EDGE: 60.5 ± 10.8	66.7	12	2	4	0	0	1	0	0	2	0
4	Krafft 2022	prospective cohort	March 2018–October 2019, USA	62.4 ± 9.5	81.8	13	0	0	3	0	0	1	0	2	3 (1 IPMN, 1 CP, benign gastric remnant wall thickening on CT)
5	Bahdi 2022²	retrospective single-arm interventional	February 2018–November 2019, USA	57 (IQR 51–62.25)	89.7	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a
6	Runge, 2021²	retrospective single-arm interventional	February 2015–March 2019, USA, UK	58 ± 11	79	97	0	8	16	0	0	0	8	18	19 (1 CP, 2 cholangioscopy, 4 PD stone, 12 other incl. Foreign body and SOD)
7	Shinn, 2021	retrospective single-arm interventional	March 2016–October 2019, USA	Median: 58	77	0	13	0	0	91	0	0	0	15	0
8	Ghandour, 2022	retrospective case–control	June 2015–September 2021, USA, UK	57.9 ± 11.1	88	38	0	3	10	0	7	7	0	6	0
9	Keane, 2022**	retrospective single-arm interventional	February 2018–May 2021, USA	58.1 ± 11.1	86.5	16	0	7	0	3	3	4	0	4	0
10	Barclay, 2022	retrospective single-arm interventional	January 2019–December 2021, Canada	Median: 67 (40–72)	57.1	6	0	0	0	0	1	0	0	0	0
11	James, 2019**	retrospective single-arm interventional	January 2016–January 2018, USA	55.5 ± 3.2	78.9	8	0	0	3	0	6	1	1	0	0
12	Sanz, 2020	cases series	October 2016–July 2019, Spain	56 ± 9.7	85.7	6	3	0	0	0	2	0	1	1	1
13	Irani, 2018	cases series	June 2015–August 2017, USA	52 (31–71)	60	3	0	0	0	0	2	0	0	0	0
Studies about EA-ERCP
14	Dellon, 2009, *	retrospective single-arm interventional	January 2008–May 2008	USA	1	50.5	75	1	4	4	100	0	0	0	0
15	Lennon, 2012**	retrospective single-arm interventional	October 2007–March 2011	USA	1	52.8 ± 14.4	76.5	12	34	54	n/a	n/a	n/a	n/a	n/a
16	Siddiqu, 2012i**	retrospective single-arm interventional	April 2008–November 2011	USA	2	58 (29–86)	62	39	79	79	n/a	48	0	0	0
17	Saleem, 2010**	retrospective single-arm interventional	April 2008–February 2010	USA	1	57 (19–85)	32	15 (cases not patients)	50	56	n/a	n/a	n/a	n/a	n/a
18	Trindade, 2015**	retrospective single-arm interventional	July 2011–September 2013	USA	1	56 (28–80)	80.4	44	n/a	n/a	100	29	10	0	0
19	Elton, 1998**	retrospective single-arm interventional	March 1994–June 1997	USA	1	53 (24–76)	55.6	3	18	18	n/a	0	4	4	0
20	Emmett, 2007	cases eries	October 2005–January 2007	USA	1	50 (40–73	50	6	14	20	n/a	0	2	0	0
21	Wagh, 2012**	prospective cohort	January 2009–June 2011	USA	1	59.3 (39–72)	86	4	7	13	n/a	1	0	0	0
22	Ali, 2018**²	retrospective single-arm interventional	December 2009–October 2016	USA	1	Median: 55 (22–75)	80.6	28 (cases)	31	35	n/a	14	0	6	1
23	Choi, 2013²	retrospective single-arm interventional	December 2005–November 2011	USA	1	56.1 ± 12.2	92.9	28	72	32/108 (DBE/total)	79	16	0	0	0
24	Sawas, 2019**	retrospective single-arm interventional	January 2015–December 2017	USA	1	62.2 ± 10.2	77.8	18	30	20/62 (BAE/total)	83.3	20	0	2	7
25	Kashani, 2018²	retrospective cohort	December 2005–July 2012	USA	1	Median: 50 (22–82)	87.4	103	103	129	n/a	26	6	0	0
Studies about LA-ERCP
26	Brockmeyer, 2015	retrospective single-arm interventional	September 2001–September 2014	USA	1	n/a	n/a	8	n/a	n/a	100	8	0	0	0
27	Patel, 2008*	retrospective single-arm interventional	January 2007–December 2007	USA	1	46.5 ± 11.2	83	6	8	8	100	6	0	0	0
28	Richardson, 2012*	retrospective single-arm interventional	January 2006–December 2011	USA	1	54.3 ± 12.6	81.8	11	13	13	91	4	0	0	0
29	Baimas-George, 2020	retrospective single-arm interventional	January 2010–December 2017	USA	1	54 (30–69)	82.5	40	40	40	100	21	8	0	0
30	Ivano, 2019*	retrospective single-arm interventional	January 2007–January 2017	Brasil	1	50 ± 14.6	57	7	7	7	100	7	0	0	0
31	Bayoumi, 2016	prospective cohort	January 2013–June 2015	Egypt, Saudi Arabia	2	44.8 ± 5.8	75	12	12	12	100	6	0	0	0
32	Snauwaert, 2015	retrospective single-arm interventional	May 2008–September 2014	Belgium	5	Median: 54 (26–79)	78.3	23	23	23	95.7	16	0	0	0
33	May, 2019	retrospective single-arm interventional	January 2009–December 2016	USA	1	55.4 ± 10.9	88	51	51	51	57	24	0	0	0
34	Paranandi, 2016*	retrospective single-arm interventional	September 2011–June 2013	UK	1	50.3 ± 14.4	100	7	7	7	71.4	4	1	0	0
35	Popowicz, 2021**	retrospective single-arm interventional	January 2007–December 2013	Sweden	n/a	42 ± 14	93	2	51	51	100	2	0	0	0
36	Gutierrez, 2009*	retrospective single-arm interventional	January 2004–December 2008	USA	1	46.2 ± 13.6	87	23	30	30	30.5	3	3	1	0
37	Lopes, 2009*	retrospective single-arm interventional	February 2003–August 2008	USA	1	43.4 ± 7.3	90	9	9	9	77.8	4	0	0	0
38	Abbas, 2018	retrospective single-arm interventional	January 2005–December 2016	USA, Brasil, Canada	34	51 (IQR: 43–61)	84	579	579	579	89	254	0	0	0
39	Wisneski, 2020**	retrospective single-arm interventional	January 2012–December 2018	USA	1	53.7 (32–73)	73	7	15	15	n/a	0	0	0	7
40	Aloun, 2021**	case series	January 2015–December 2019	Saudi Arabia	1	Median: 35 (26–45)	66.6	1	3	3	n/a	1	0	0	0
41	Li, 2021*	prospective cohort	January 2013–December 2018	Germany	1	48.7 ± 15.3	55.6	9	20	20	100	7	0	0	0
42	Ponsky, 2017	retrospective single-arm interventional	January 2008–October 2016	USA	1	53.9 (32–64)	100	9	9	9	0	0	0	0	0
43	Saleem, 2012*	retrospective single-arm interventional	February 2003–March 2010	USA	1	50.9 ± 12.6	80	15	15	15	33.3	4	0	0	0
44	Habenicht, 2018	retrospective single-arm interventional	September 2012–January 2016	USA	1	55.8 (29–67)	n/a	16	16	16	100	15	0	0	0
45	Roberts, 2008	retrospective single-arm interventional	n/a	USA	1	44.6 ± 9.5	100	5	5	5	20	1	0	0	0
46	Clapp, 2021	retrospective single-arm interventional	January 2012–December 2017	USA	1	44.8 ± 10.6	83.3	12	12	12	n/a	n/a	n/a	n/a	n/a
47	Tzedakis, 2019*	retrospective single-arm interventional	February 2014–May 2015	France	1	42 ± 9.8	100	4	5	5	100	2	2	0	0
48	Falcao, 2012*	prospective cohort	January 2003–December 2010	Brazil	3	35.3 ± 6.7	82.6	23	23	23	100	14	0	0	0
49	Frederiksen, 2017	retrospective single-arm interventional	January 2010–January 2016	Denmark	1	Median: 46 (25–65)	86	29	29	31	100	29	0	0	0
50	Lim, 2017	retrospective single-arm interventional	March 2011–February 2016	USA	1	50.5 (27–72)	100	35	35	35	0	0	0	0	0
51	Telfah, 2020	retrospective single-arm interventional	January 2010–December 2019	UK	1	64 (34–73)	75	12	12	12	100	0	4	0	0
52	Koggel, 2021²	retrospective single-arm interventional	January 2009–August 2019	The Netherlands	1	Median: 53.5 (27–72)	81.4	86	86	100	93	61	25	0	0
53	Liljegard, 2022	case–control	January 2007–December 2020	Sweden	1	Median: 58 (28–73)	93	14	28	42	100	14	0	0	0
54	Grimes, 2015***	retrospective single-arm interventional	October 2004–January 2014	USA	1	48.5 (23–69)	94	41	41	85	12	5	0	0	0
55	Bowman, 2016	retrospective single-arm interventional	n/a	USA	2	48.8 ± 13.7	27	11	15	16	54.5	4	0	1	0
56	Mohammad, 2019	retrospective single-arm interventional	April 2008–April 2016	USA	1	54 ± 13	81.25	32	32	32	93	16	2	0	0
57	AlMasri, 2022	retrospective single-arm interventional	October 2007–July 2019	USA	1	60 (IQR: 50–67)	80.9	131	131	131	82.5	102	0	3	0
58	Ceppa, 2007	retrospective single-arm interventional	July 1999–January 2005	USA	1	44 (32–56)	80	5	10	10	n/a	4	0	0	0
59	Bertin, 2011	retrospective single-arm interventional	July 2004–January 2009	USA	1	n/a	n/a	22	22	22	0	0	0	0	0
60	Levy, 2022	retrospective single-arm interventional	April 2010—July 2020	USA	3	58.4 ± 12.2	84.9	50	50	50	n/a	n/a	n/a	n/a	n/a
Comparative studies
61	Kröll, 2020	retrospective cohort	January 2013–March 2019	Switzerland	1	LA-ERCP: 45.5 (72–28); EDGE: 50.5 (49–52)	EDGE: 100; LA-ERCP: 78	EDGE: 2; LA-ERCP: 14	19	19	82	EDGE: 2, LA-ERCP: 11	0	0	0
62	Kedia, 2019	retrospective cohort	May 2005—June 2017	USA	3	EDGE: 56 (35–82); LA-ERCP: 55 (33–80)	EDGE: 86; LA-ERCP: 86	EDGE: 29; LA-ERCP: 43	72	72	93	54 (EDGE: 21, LA-ERCP: 33)	0	0	0
63	Kochhar, 2020	retrospective cohort	January 2015—July 2019	USA	1	EDGE: 60.77 ± 11.4; LA-ERCP: 60.78 ± 12.67; EA-ERCP: 68.58 ± 15.09	EDGE: 77; LA-ERCP: 67; EDGE: 67	EDGE: 26; LA-ERCP: 18; EA-ERCP: 12	56	56	n/a	EDGE: 10, LA-ERCP: 14, EA-ERCP: 5	EDGE: 1, LA-ERCP: 1, EA-ERCP: 2	0	0
64	Tonnesen, 2020	retrospective cohort	May 2013–December 2017	Norway	2	EA-ERCP: 51 (37–72); LA-ERCP: 48.8 (25–77)	EA-ERCP: 84; LA-ERCP: 73	EA-ERCP: 31; LA-ERCP: 37	68	79	28.5	EA-ERCP: 17, LA-ERCP: 31	0	0	0
65	Schreiner, 2012****	retrospective cohort	September 2007—May 2011	USA	1	EA-ERCP: 53; LA-ERCP: 52	EA-ERCP: 97; LA-ERCP: 79	EA-ERCP: 32; LA-ERCP: 24	56	56	88	EA-ERCP: 10, LA-ERCP: 3	0	EA-ERCP: 2, LA-ERCP: 1	0
66	Bukhari, 2018	retrospective cohort	January 2014–December 2016	USA, Denmark	5	EA-ERCP: 61.8 ± 11.5; EDGE 52.5 ± 13.4	EA-ERCP: 60; EDGE: 90	EDGE: 30; EA-ERCP: 30	60	60	97	EA-ERCP: 23, EDGE: 20	0	0	EA-ERCP: 5, EDGE: 2
67	Wang, 2020	retrospective cohort	January 2009–December 2019	USA	2	EDGE: 59.3 ± 6.5; LA-ERCP: 50.6 ± 15.9; EA-ERCP: 55.3 ± 14.3	EDGE: 89; LA-ERCP: 90; EA-ERCP: 67	EDGE: 18; LA-ERCP: 42; EA-ERCP: 70	130	130	87,5	EA-ERCP: 28, LA-ERCP: 20, EDGE: 11	EA-ERCP: 9, LA-ERCP: 5, EDGE: 0	EA-ERCP: 7, LA-ERCP: 0, EDGE: 4	0

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*Demographic data were calculated based on individual datasets available in the study

**Demographic data or results refer to the entire study population, including patients, or endoscopic procedure other than ERCP, or patients with other types of surgically altered anatomy

***Results for ERCP procedures were not directly reported in the study but were deduced by the authors from information from the text

****Indications were calculated for the number of procedures

¹Mean ± SD or (range) or median (IQR) unless stated otherwise

²Results were calculated for the number of procedures

CDL, choledocholithiasis; SOD, sphincter of Oddi dysfunction; ERCP, endoscopic retrograde cholangiopancreatography; EDGE, endoscopic ultrasound-directed transgastric ERCP; LA-ERCP, laparoscopy-assisted ERCP; EA-ERCP, enteroscopy-assisted ERCP; SD, standard deviation; IQR, interquartile region

Meta-analysis

Primary Outcomes

Technical success

The technical success rate was reported in 12 studies for EDGE [13–24], 35 for LA-ERCP [14, 21, 24–56], and 8 for EA-ERCP [16, 52, 57–62]. The outcome was achieved in 96% (CI 92–98%; n = 212/214), 93% (CI 91–95%; n = 718/750), and 77% (CI 69–83%; n = 137/176) of patients undergoing EDGE, LA-ERCP, and EA-ERCP, respectively, whereas the heterogeneity measure of total I² was not substantial (I² = 0%, CI 0–33%). Subgroup differences were significant between the EA-ERCP and EDGE, and EA-ERCP and LA-ERCP groups (p < 0.05) (Fig. 2, S1A).

Fig. 2 — Technical success rates of EDGE, LA-ERCP and EA-ERCP. Summary forest plot of pooled proportions of technical success for each procedure and significant subgroup differences. ERCP, endoscopic retrograde cholangiopancreatography; EDGE, endoscopic ultrasound-directed transgastric ERCP; LA-ERCP, laparoscopy-assisted ERCP; EA-ERCP, enteroscopy-assisted ERCP; CI, confidence interval; I², total heterogeneity measure

Clinical success

The clinical success was assessed in 11 studies for EDGE [13–21, 23, 24], 37 for LA-ERCP [14, 21, 24–56, 63, 64], and 10 for EA-ERCP [14, 16, 52, 57–62, 64]. ERCP was successfully performed in 93% (CI 87–97%; n = 182/188), 92% (CI 90–94%; n = 1279/1366), and 64% (CI 56–71%; n = 181/277) of the patients in the EDGE, LA-ERCP, and EA-ERCP groups, respectively. The total I² value was not substantial (I² = 14%, CI, 0–60%). Subgroup differences between EDGE or LA-ERCP and EA-ERCP were significant (p < 0.05) (Fig. 3, S2A).

Fig. 3 — Clinical success rates of the investigated ERCP techniques. Summary forest plot of the pooled proportions of clinical success for each procedure and significant subgroup differences. ERCP, endoscopic retrograde cholangiopancreatography; EDGE, endoscopic ultrasound-directed transgastric ERCP; LA-ERCP, laparoscopy-assisted ERCP; EA-ERCP, enteroscopy-assisted ERCP; CI, confidence interval; I², heterogeneity measure

Secondary Outcomes

Overall early adverse event rate

A total of 11 studies reported adverse events for EDGE [13–19, 21–24], 37 for LA-ERCP [14, 21, 22, 24–40, 42–55, 63–65], and 9 for EA-ERCP [14, 16, 22, 52, 58, 59, 61, 62, 64]. Complications were diagnosed in 20% (CI 12–31%; n = 33/181), 19% (CI 14–24%; n = 280/1392), and 13% (CI 8–22%; n = 31/247) of patients in the EDGE, LA-ERCP, and EA-ERCP groups, respectively. The total I² value was substantial (I² = 59%, CI 0–86%). Subgroup differences were not significant (p = 0.49) (Fig. 4, S3A).

Fig. 4 — Forest plot showing the overall complication rates of each technique. Summary forest plot of pooled proportions of overall complications for each procedure and subgroup differences that were not significant. ERCP, endoscopic retrograde cholangiopancreatography; EDGE, endoscopic ultrasound-directed transgastric ERCP; LA-ERCP, laparoscopy-assisted ERCP; EA-ERCP, enteroscopy-assisted ERCP; CI, confidence interval; I², heterogeneity measure

Procedure-related and pooled perforations

Procedure-related perforations were reported in 11 studies on EDGE [13–19, 21–24], 36 on LA-ERCP [14, 21, 22, 24–34, 36–40, 42–56, 63, 65], and 8 on EA-ERCP [16, 22, 52, 58–62]. Perforation was diagnosed in 6% (CI 3–11%; n = 5/181), 3% (CI 2–4%; n = 17/1324), and 3% (CI 1–7%; n = 1/185) of patients undergoing EDGE, LA-ERCP, and EA-ERCP, respectively, due to a specific intervention. The total I² value was non-negligible (I² = 3%, CI 0–35%). The subgroup differences were not statistically significant (p = 0.29). Pooled perforation rates (including ERCP-related ones) were different only in the LA-ERCP group, as was reported by 35 studies (Li et al. not included) (3%, CI 2–4%; n = 21/1315); subgroup differences remained not significant (p = 0.33) (Fig. S4A).

Overall bleeding rate

Data on the number of patients with intervention-related bleeding were provided in 11 studies for EDGE [13–19, 21–24], 33 for LA-ERCP [21, 22, 24, 26–34, 36–40, 42–56, 63], and 7 for EA-ERCP [16, 22, 52, 58, 59, 61, 62]. The bleeding rates were 5% (CI 2–9%; n = 5/181), 4% (CI 3–6%; n = 20/1101), and 8% (CI 3–17%; n = 4/146) in the EDGE, LA-ERCP, and EA-ERCP groups, respectively, whereas the total I² was not consistent (I² = 7%, CI 0–45%). The subgroup differences were not statistically significant (p = 0.37) (Fig. S5A).

Post-ERCP pancreatitis

Several post-ERCP pancreatitis (PEP) cases were reported in 11 studies for EDGE [13–19, 21–24], 36 for LA-ERCP [14, 21, 22, 24–34, 36–40, 42–56, 63, 65], and 8 for EA-ERCP [14, 16, 22, 52, 58, 59, 61, 62]. PEP was observed in 4% (CI 2–9%; n = 2/181), 7% (CI 6–8%; n = 74/1324), and 7% (CI 4–12%; n = 12/216) of patients undergoing EDGE, LA-ERCP, and EA-ERCP, respectively. The total I² value was negligible (I² = 0%; CI 0–30). Subgroup differences did not reach statistical significance (p = 0.50) (Fig. S6A).

Acute cholangitis and procedure-related mortality could not be calculated because of the scarcity of data.

Additional results and those based on comparative studies are described in the Supplementum (Document 3 and Figs. S1B–6B and S7–10).

Risk of bias Assessment

The results of the risk of bias assessment are presented in Tables S3 and S4. Comments on RoB can be found in Supplementum (Sec. 3.4.).

Publication bias

Funnel plots of publication bias and detailed comments can be found in the Supplementum (Sec. 3.3., Figs. S1A–6A and S7–10A).

Sensitivity Analysis

The results are shown in Supplementum Figures S11–S18 and remarks can be found in Supplementum, Sec. 3.5.

Certainty of Evidence

The level of evidence was very low for each outcome with indirect comparisons and low for direct comparisons. A summary of these findings is presented in Supplementum, Tables S5–S10 and Sec. 3.6.

Systematic Review

Acute Cholangitis

Acute cholangitis was reported in 11 studies for EDGE [13–19, 23, 24, 66, 67], 35 studies for LA-ERCP [14, 21, 22, 24–34, 36–40, 42–56, 63], and 9 studies for EA-ERCP [16, 22, 52, 58–62, 68]. The rates were 1/373, 8/1272, and 1/255, respectively.

Mortality

Procedure-related mortality in the study population was 0/373 for 13 studies [13–19, 21–24, 66, 67] and 1/1435 for 39 studies [14, 21, 22, 24–56, 63–65], and 0/286 for 11 studies [14, 16, 22, 52, 58–62, 64, 68] for EDGE, LA-ERCP, and EA-ERCP, respectively.

Procedure Duration for EDGE

Some studies presented mean lengths of 79 (standard deviation ( ±) 31), 49.8 (± 26.5), and 92 (± 47) minutes for EDGE in 30, 26, and 178 patients [16, 22, 66]. Another study included 29 patients and reported a mean length of 73 min (range 24–230) [21]. Kröll et al. (2020) reported a median procedure length of 101 min (interquartile range (IQR) 56–47 min), including only two patients [24].

Length of Hospital Stay for EDGE

The mean length of hospital stay was 0.8 days (range 0–5) for 29 patients, 1.61 (± 1.7) days for 26 patients, and 2.9 (± 4.6) days for 75 procedures [21, 22, 69]. Others reported a median hospital stay of 1 (IQR 1–3) day for 30 patients and 0 (IQR 0–2) day for 178 procedures [16, 66].

Length of Hospital Stay for EA-ERCP

The mean length of hospital stay was 3.26. (± 4.36) days for 12 interventions and 1.28 (range 1–8) for 19 procedures [22, 52]. Others reported a median hospital stay of 10.5 (IQR, 1.5–13) days for 30 patients [16].

Predictive Factors for Fistula Formation and the Risk of Weight Gain

In a retrospective review, 9 of 22 patients developed persistent fistulas 8 weeks after removal of 20-mm LAMS, and the LAMS dwell time was significantly longer in those with persistent fistulas than in those with spontaneous fistula closure (77 vs. 35 days, p = 0.03). It also reported unintentional weight gain for more patients with persistent fistula compared to patients with spontaneous fistula closure. Weight increase was of at least 2.5% of their preinterventional weight, but the difference between the groups was not significant though (p = 0.22) [70]. A case–control study (25 patients with persistent fistula vs. 50 patients with spontaneous fistula closure) found that LAMS dwell time ≥ 40 days was a significant predictor of persistent fistula formation (79.2%, n = 19/24 vs. 45.8%, n = 22/48; OR 4.5 (CI 1.5–14.0)). Patients who developed a fistula gained more than 5% body weight (n = 8/24, 33.3%) than those without a fistula (n = 4/39, 10.3%), which was a significant increase (OR 4.4, CI 1.2–16.7; p = 0.03) [69]. In another study, 5 of 13 patients developed a fistula following endoscopic closure [67]. James et al. found 1 patient developing persistent fistula from 11 followed-up individuals (7 were lost for follow-up). This patient gained 5.6 kg in a 7-month period, and after fistula closure, it lost weight again. The mean weight gain in all patients was 1.7 kg (SD ± 8.6 kg) after a mean 281 (± 177) days of follow-up [13].

Qualitative Assessment of Studies Not Suitable for Statistical Synthesis

A systematic review of these studies can be found in the Supplementary information.

Discussion

The selection of an appropriate ERCP procedure for RYGB patients should consider the success and complication rates of potential ERCP techniques. This study aimed to analyze these modalities comprehensively.

Technical and Clinical Success

Results of our direct and indirect comparisons suggested that the technical and clinical success rates may be significantly higher for EDGE and LA-ERCP than for EA-ERCP. The only exception was a direct comparison of LA-ERCP and EA-ERCP regarding overall adverse event rates, but the number of comparisons was minimal.

Previous reviews reported similar technical success rates for EA-ERCP, as observed in our work [7] [11], while Gkolfakis et al. (2023) reported higher technical success for EA-ERCP [10]. Studies reporting EA-ERCP excluded push enteroscopy cases; however, this did not hinder comparability with our work, as only three push enteroscopy cases were included in our study, all successful [57]. Table 2 details the results of previous meta-analyses.

Table 2.

Summary table of previous reviews

Publication data	Number of studies	Number of procedures/patients	Technical success	Clinical success	Overall adverse events	Perforations	Bleeding	Post-ERCP pancreatitis	Procedure duration	Indications	Other information
EA-ERCP
Ayoub 2020	12	459 procedures	80.0% (CI 71.3–87.4)	73.2% (CI 62.5–82.6)	6.5% (CI 3.9–9.6)	1% (n = 6/459)	n/a	5% (n = 23/459) 10 studies	100.5 min (SD ± 19.2)	CDL 74% (n = 280/380)	n/a
Dhindsa 2020	5	205 patients	71.4% (CI 51–85.7)	58.7% (CI 27.6–84.1)	8.4% (CI 5–13.6)	1.8% (CI 0.7–4.7)	1.5% (CI 0.4–5)	6.3% (CI 3.7–10.4)	n/a	n/a	TS: cannulation, CS: clinical improvement and resolution
Klair 2020	10	398 procedures	75.3% (CI 64.5–83.6)	64.8% (CI 53.1–74.9)	9.0% (CI 5.4–14.5)	n/a	n/a	n/a	n/a	n/a	CS: cannulation
Connel 2022	4	47 patients	n/a	61.5% (CI 44.3–76.3)	5.9% (n = 2)	n/a	n/a	5.9% (n = 2)	94.1 min	n/a	n/a
Gkolfakis 2023	55	6853 procedures	87.3 (CI 85.3–89.4)	69.1 (CI 65.3–72.9)	5.7 (CI 4.50–6.80)	n/a	n/a	n/a	n/a	CDL 1/3, malignancy 11% (n = 753)	PEP percentage ranged between 1.7% and 4.1% and cholangitis was diagnosed in 0.2–1.6% of all cases. Other types of surgically altered anatomy were also included
LA-ERCP
Ayoub 2020	14	886 procedures	98.5% (CI 97.6–99.2)	97.9% (CI 96.7–98.7)	19.0% (CI 12.6–26.4)	1% (n = 10/847)	n/a	6% (n = 53/847)	158.4 min (SD ± 20)	48% (408/847)	n/a
Dhindsa 2020	18	939 patients	95.3% (CI 91.3–97.5)	92.9% (CI 83.9–97.1)	17.4% (CI 14–21.5)	2.2% (CI 1.3–3.7)	3.7% (CI 2.6–5.4)	6.8% (CI 5.3–8.8)	n/a	n/a	n/a
Connel 2022	33	577 patients	n/a	100% (CI 99–100)	12.8% (n = 44)	n/a	2.6% (n = 9)	4.9% (n = 17)	133.1 min	n/a	n/a
Gkolfakis 2023	18	767 procedures	99.1% (CI 98.6–99.7)	98.5% (CI 97.8–99.2)	15.1% (CI 9.40–20.8)	n/a	n/a	n/a	n/a	n/a	PEP percentage ranged between 1.7% and 4.1% and cholangitis was diagnosed in 0.2–1.6% of all cases
EDGE
Dhindsa 2020	4	124 patients	95.5% (CI 84.2–98.8)	95.9% (CI 81.2–99.2)	21.9% (CI 14.6–31.4)	2.2% (CI 0.6–7.4)	6.6% (CI 3.3–13)	2.2% (CI 0.6–7.4)	n/a	n/a	n/a
Connel 2022	8	103 patients	n/a	97% (CI 90–100)	24.3% (n = 17)	n/a	1.5% (n = 1)	11.4% (n = 8)	67.4 min	n/a	Stent dislodgement 7.1% (5), malposition 4.3% (3)
Gkolfakis 2023	9	253 procedures	97.9% (CI 96.4–99.4)	97.9% (CI 96.3–99.4)	13.1% (CI 7.50–18.8)	n/a	n/a	n/a	n/a	n/a	PEP percentage ranged between 1.7% and 4.1% and cholangitis was diagnosed in 0.2–1.6% of all cases
Su 2023	14	585 procedures	98% (CI 96–99), 13 studies	94 (CI 90–99), 7 studies	12% (CI 0.09–0.159), 14 studies	n/a	n/a	n/a	n/a	n/a	LAMS dislodgement 4%(95% CI 3–6), 14 studies). The overall AE rate was lower in the 20-mm than in the 15-mm LAMS group (OR = 5.79; 95% CI 2.35 to 14.29, 4 studies). No diff in access routes (6 studies) or number of stages (3 studies)

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CDL, choledocholithiasis; PEP, post-ERCP pancreatitis; LAMS, lumen-apposing metall stent; CI, confidence intervall; SD, standard deviation; TS, technical success; CS, clinical success; ERCP, endoscopic retrograde cholangiopancreatography; EDGE, endoscopic ultrasound-directed transgastric ERCP; LA-ERCP, laparoscopy-assisted ERCP; EA-ERCP, enteroscopy-assisted ERCP

Clinical success rates for EA-ERCP from previous studies were similar to ours, with only slight differences. EA-ERCP was associated with lower clinical success rates in one case [8] and similar clinical success rates in two cases compared to our study [7, 10]. Klair et al. (2020) defined clinical success as cannulation success, and their results were consistent with ours [11]. Dhindsa et al. (2020) described technical success as cannulation and clinical success as clinical improvement following therapeutic intervention [9]. These outcomes corresponded best to clinical success, as defined in our review, and their results were similar.

Reviews on the technical and clinical success of EDGE and LA-ERCP found results very similar to our meta-analysis [7–10, 12], with the addition of Dhindsa (2020) and Klair (2020) et al. defined technical and clinical success as described above. These findings can be explained by the technical differences in these ERCP methods compared to EA-ERCP, which allows for shorter and faster access routes to the papilla of Vater.

Complications

Pooled and individual complications, namely procedure-related perforations, bleeding, and PEP, may not occur significantly more frequently with EDGE or LA-ERCP than with EA-ERCP. These results contradict previous studies that found that EA-ERCP was associated with significantly lower adverse event rates than the other two techniques [7–12]. Some authors reported lower pooled complication rates for EDGE and LA-ERCP [8, 10, 12], while all previous reviews reported lower adverse event rates in the EA-ERCP group than in our review [7–12]. The methodological differences between these reviews and ours can explain this. Connel et al. (2022) investigated balloon EA-ERCP procedures only, and their primary outcome was that they focused exclusively on stone extraction. Gkolfakis et al. (2023) also reported higher technical success rates with EA-ERCP. However, most of the studies on EA-ERCP were performed on patients with other types of surgically altered anatomy. Differences in the populations may have contributed to these different results. Moreover, the results of some studies were calculated on a per-procedure basis [7, 10–12], and others may have included overlapping populations [10, 12]. In addition, the rates of individual adverse events were often not directly comparable to our results because of the limited data availability (Table 2). Furthermore, these studies defined overall complications as the sum of PEP, perforations, cholangitis, and bleeding [10, 11]. In some cases, complications were not clearly defined in advance [7, 8, 12]. Our study included a more comprehensive range of adverse events for the overall complications, notably for EDGE and LA-ERCP. Despite this, our analysis had no significant differences in the complication rates.

Limitations

Most of the included studies were retrospective in design, with several intrinsic drawbacks, such as the risk of selection and reporting bias. We tried to address them in multiple ways. Reporting bias was mitigated by enrolling only studies with consecutively collected data. Bias in patient selection was addressed by standardizing the population as much as possible. Namely, we implemented rigorous selection criteria for patients regarding anatomy (RYGB only) and the type of performed procedures (ERCP only). Further, the baseline characteristics of the included studies (Table 1) can reveal similarities regarding age, sex, and indication in each ERCP group. Multivariate analysis was not possible due to scarce data, but a qualitative analysis could also lower the risk of systematic error. According to this, patients receiving LA-ERCP tended to be younger than those in the other two groups. Beyond that, most of the indications were choledocholithiasis, but even other indications were mainly biliary (papillary diseases (mostly SOD) or biliary stenosis). Besides, most of the study populations comprised mainly female patients. In summary, the only difference in baseline characteristics may be observed in age distribution. It could be explained by the preference for less invasive procedures in the older population. In our opinion, it should not be considered as a determining factor behind procedural outcomes because none of the procedures had to be stopped or altered due to comorbidities or physical conditions of the patients. Besides, although patients undergoing EDGE or EA-ERCP tended to be older, they were still not or just slightly above the age of 65 years.

Unfortunately, bias in procedure selection of observational studies arises from unmeasured confounders regarding the indication and is induced by the physicians. Because of this, it cannot be adjusted for in statistical analysis.

Another limitation of our work was that we included studies with smaller sample sizes if they included consecutive patients to increase the amount of data. This, however, widened the confidence interval of our calculations. In addition, variations in expertise in different techniques may have affected the results. Furthermore, the QoE needed to be higher for the assessed outcomes due to deficiencies in the retrospective studies included.

Strengths

To our knowledge, this study included the largest number of studies reporting ERCP in the RYGB population. We applied a rigorous methodology for study selection and statistical synthesis. The outcomes were based on predefined criteria in our study. When possible, we performed direct comparisons associated with higher statistical values. In all but one case, the results of the direct and indirect comparisons were similar, confirming our study’s conclusion. Contrary to some previous reviews [7, 10–12], to ensure statistical independence of the data, we calculated our results based on the number of patients and not on the number of procedures. Studies with overlapping populations were excluded from the meta-analysis.

Implications for the Future

We propose some factors to be considered to help in daily clinical practice. First, an alimentary limb longer than 150 cm makes reaching the papilla very difficult with EA-ERCP. Further, LA-ERCP should be prioritized in patients with gallbladder in situ with choledocholithiasis as an indication and may be the most reasonable choice in cases of unclear chronic abdominal pain, as well [24, 52]. Beyond that, LA-ERCP or EA-ERCP may be safer choices in urgent settings, as single-session EDGE has often been associated with complications with LAMS. However, using a suturing device could make single-session EDGE safer [20]. Furthermore, multiple interventions are possible with all three interventions. In the case of EDGE, the risk of persistent fistulae formation and the associated weight gain increases with longer LAMS dwell time. If a fistula is present, argon plasma coagulation and over-the-scope clip placement or revisional surgery with gastro-gastric fistula takedown may be required for fistula closure [13, 70, 71]. An LA-ERCP procedure can also be finished by placing a G-tube in the gastrostomy, allowing for repeated ERCP [35–37, 63]. However, this carries an increased risk of gastrostomy site infections. Repeating EA-ERCP multiple times in a patient may be exhaustive and the least effective method and thus may be considered only if the other two techniques are not available locally or contraindicated (e.g., due to adhesions and inability to identify the remnant stomach with EUS).

Laparoscopic common bile duct exploration (LCBDE) for stone removal is an effective option for RYGB patients [72]. The bleeding, acute cholangitis, and pancreatitis rates of LCBDE seem to be lower than those of ERCP. However, bile leaks (2.3–16.7%) and retained stones (0–5%) are not uncommon and tend to be associated with different approaches of LCBDE (i.e., transcystic or transcholedochal). Furthermore, despite LCBDE being minimally invasive, it is still an operation with a low but still not negligible long-term risk of bile duct strictures (ca. 0.8%) and adhesions, especially if choledochotomy was performed. These facts imply that the decision between LCBDE and preoperative ERCP requires further clarification.

Percutaneous transhepatic cholangiography (PTC) is also safe in RYGB patients, but we recommend it as a salvage technique after a previously failed ERCP due to the limited intervention possibilities of the procedure.

Our results suggest that more centers should consider performing EDGE for patients with RYGB. Furthermore, managing these patients may require more specialized centers and multidisciplinary decision-making.

This study highlights the need for more prospective, controlled, multicenter trials with larger sample sizes to improve the QoE. We did a rough estimation of the sample size for an RCT where the main outcome is the complication proportion. We calculated for 10% difference with 5% first type error and 90% power, assuming a 10% loss of follow-up; the number of patients needed to be involved in such an RCT would be about 1135, which is probably far too many ever to be done. Because of that, prospective observational trials based on standardized protocols were more feasible. The optimal target population for such a trial could be bariatric RYGB patients with their gallbladder already removed and an alimentary limb shorter than 150 cm in a non-urgent setting. This concept would minimize the risk of deviation from the intended procedure.

Our results also stress the importance of the statistical independence of the data. This highlights the importance of accurate patient-based reporting of results in future studies.

Conclusion

Our findings suggest that EDGE and LA-ERCP may be better than EA-ERCP in reaching the papilla and performing successful ERCP, while they may be as safe as EA-ERCP in patients with an RYGB anatomy.

Supplementary Information

Below is the link to the electronic supplementary material.

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Supplementary file 1 Figure S1A. Technical success based on indirect comparison. a: Forest plot depicting proportions of technical success for each procedure and showing significant subgroup differences. b: Funnel plot showing potential publication bias. ERCP endoscopic retrograde cholangiopancreatography, EDGE endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, I2: total heterogeneity measure. (JPG 188 KB)

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Supplementary file 2 Figure S1B. Technical success based on direct comparison. Forest plot comparing technical success between EDGE and LA-ERCP. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, OR: odds ratio, CI: confidence interval, I2: total heterogeneity measure. (JPG 65 KB)

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Supplementary file 3 Figure S2A. Clinical success based on indirect comparison a: Forest plot depicting clinical success rates for each procedure and showing significant subgroup differences. b: Funnel plot exploring publication bias for each study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, I2: total heterogeneity measure. (JPG 189 KB)

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Supplementary file 4 Figure S2B. Clinical success based on direct comparisons a: Forest plot comparing clinical success between EDGE and LA-ERCP. b: Forest plot comparing clinical success between LA-ERCP and EA-ERCP. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, OR: odds ratio, CI: confidence interval, I2: total heterogeneity measure. (JPG 116 KB)

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Supplementary file 5 Figure S3A. Overall complication rates based on indirect comparison. a: The forest plot depicts overall complication rates for each procedure and shows that subgroup differences were not significant. b: Funnel plot exploring publication bias for each study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, I2: total heterogeneity measure. (JPG 159 KB)

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Supplementary file 6 Figure S3B. Overall complication rates based on direct comparison. a: Forest plot comparing overall complication rates between EDGE and LA-ERCP. b: Forest plot comparing overall complication rates between EDGE and EA-ERCP. c: Forest plot comparing overall complication rates between LA-ERCP and EA-ERCP. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, OR: odds ratio, CI: confidence interval, I2: total heterogeneity measure. (JPG 203 KB)

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Supplementary file 7 Figure S4A. Procedure-related perforation rates with indirect comparison. a: The forest plot depicts procedure-related perforation rates for each procedure and shows that subgroup differences were not significant. b: Funnel plot exploring publication bias for each study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, I2: total heterogeneity measure. (JPG 189 KB)

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Supplementary file 8 Figure S4B. Procedure-related perforation rates with direct comparison. Forest plot comparing procedure-related perforation rates between EDGE and LA-ERCP. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, OR: odds ratio, CI: confidence interval, I2: total heterogeneity measure. (JPG 67 KB)

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Supplementary file 9 Figure S5A. Proportions of overall bleeding rates with indirect comparison.a: The forest plot depicts procedure-related perforation rates for each procedure and shows that subgroup differences were not significant. b: Funnel plot exploring publication bias for each study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, I2: total heterogeneity measure (JPG 172 KB)

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Supplementary file 10 Figure S5B. Proportions of overall bleeding rates with direct comparison. Forest plot comparing overall bleeding rates between EDGE and LA-ERCP. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, OR: odds ratio, CI: confidence interval, I2: total heterogeneity measure. (JPG 60 KB)

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Supplementary file 11 Figure S6A. Proportions of post-ERCP pancreatitis rates with indirect comparison. a: The forest plot depicts post-ERCP pancreatitis rates for each procedure and shows that subgroup differences were not significant. b: Funnel plot exploring publication bias for each study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, I2: total heterogeneity measure. (JPG 191 KB)

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Supplementary file 12 Figure S6B. Proportions of PEP rates with direct comparison. a: Forest plot comparing PEP rates between LA-ERCP and EA-ERCP .b: Forest plot comparing PEP rates between EDGE and LA-ERCP. c: Forest plot comparing PEP rates between EDGE and EA-ERCP. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, PEP: post-ERCP pancreatitis, OR: odds ratio, CI: confidence interval, I2: total heterogeneity measure. (JPG 181 KB)

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Supplementary file 13 Figure S7. Persistent fistulae formation a: Forest plot about the rate of fistulae formation following EDGE. b: Funnel plot investigating publication bias (right). EDGE: endoscopic ultrasound-directed transgastric ERCP, CI: confidence interval, I2: total heterogeneity measure. (JPG 144 KB)

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Supplementary file 14 Figure S8. Complications with LAMS. A: Forest plot representing pooled complication rates occurring with LAMS (left). Funnel plot representing publication bias of the studies reporting on LAMS complications (right). B: Forest plot representing dislodgement rates occurring with LAMS (left). Funnel plot representing publication bias of the studies reporting on LAMS dislodgements (right). LAMS: lumen-apposing metall stent, CI: confidence interval, I2: total heterogeneity measure. (JPG 238 KB)

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Supplementary file15 Figure S9. Length of hospital stay of patients undergoing LA-ERCP. a: Forest plot of studies reporting on length of hospital stay after LA-ERCP. b: Funnel plot of studies reporting on length of hospital stay after LA-ERCP. LA-ERCP: laparoscopy-assisted ERCP, CI: confidence interval, MRAW: untransformed (raw) means, I2: total heterogeneity measure. (JPG 146 KB)

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Supplementary file16 Figure S10A. Procedure duration of LA-ERCP. a: Forest plot of studies reporting on the length of LA-ERCP procedure. b: Funnel plot showing potential publication bias. LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, MRAW: untransformed (raw) means, min: minutes, I2: total heterogeneity measure. (JPG 164 KB)

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Supplementary file17 Figure S10B. Procedure duration of EA-ERCP. Forest plot of studies reporting on length of EA-ERCP procedure. EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval, MRAW: untransformed (raw) means, min: minutes, I2: total heterogeneity measure. (JPG 70 KB)

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Supplementary file18 Figure S11. Sensitivity analysis of indirect comparison of technical success rates using dfbetas The Logit scale represents how much the estimated effect size changes by leaving out the given study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP. (JPG 69 KB)

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Supplementary file 19 Figure S12. Leave-one-out sensitivity analysis values about clinical success using the confidence interval method. Sensitivity analysis of studies reporting clinical success using estimates with confidence intervals if leaving out a given study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval. (JPG 171 KB)

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Supplementary file 20 Figure S13. Leave-one-out sensitivity analysis values about overall adverse event rates using the confidence interval method. Sensitivity analysis of studies reporting overall adverse events using estimates with confidence intervals if leaving out a given study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval. (JPG 164 KB)

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Supplementary file 21 Figure S14. Leave-one-out sensitivity analysis values about procedure-related perforation rates using the confidence interval method. Sensitivity analysis of studies reporting on procedure-related perforations using estimates with confidence intervals if leaving out a given study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval. (JPG 160 KB)

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Supplementary file 22 Figure S15. Leave-one-out sensitivity analysis values about overall bleeding rates using the confidence interval method Sensitivity analysis of studies reporting overall bleeding rates using estimates with confidence intervals if leaving out a given study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, CI: confidence interval. (JPG 152 KB)

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Supplementary file 23 Figure S16. Sensitivity analysis of PEP rates with leave-one-out analysis using dfbetas. The Logit scale represents how much the estimated effect size changes, leaving out the given study. ERCP: endoscopic retrograde cholangiopancreatography, EDGE: endoscopic ultrasound-directed transgastric ERCP, LA-ERCP: laparoscopy-assisted ERCP, EA-ERCP: enteroscopy-assisted ERCP, PEP: post-ERCP pancreatitis. (JPG 66 KB)

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Supplementary file 24 Figure S17. Leave-one-out sensitivity analysis values about persistent fistulae development using forest plot. Sensitivity analysis of studies reporting persistent fistulae rates using estimates with confidence intervals if leaving out a given study. Effect size: the pooled effect size without the given study, CI: confidence interval, I2: heterogeneity value without the presented study, Std residual: the studentized residuals which show the deleted residual divided by its estimated standard deviation, Dffits: the difference in fits. It quantifies the number of standard deviations the fitted value changes without the given study, Cook’s dist.: Cook’s distance depends on both the residual and leverage of the omitted study, Covariance ratio: the covariance ratio showing the change in the determinant of the covariance matrix of the effect size, Hat value: the value of the hat matrix without the given study. (JPG 143 KB)

11695_2024_7459_MOESM25_ESM.jpg^{(226KB, jpg)}

Supplementary file 25 Figure S18. Leave-one-out sensitivity analysis about complications occurring with LAMS using forest plot. a: Sensitivity analysis of studies reporting pooled complication rates with LAMS using estimates with confidence intervals if leaving out a given study. b: Sensitivity analysis of studies reporting LAMS dislodgement rates using estimates with confidence intervals if leaving out a given study. Effect size: the pooled effect size without the given study, CI: confidence interval, I2: heterogeneity value without the presented study, Std residual: the studentized residuals which show the deleted residual divided by its estimated standard deviation, Dffits: the difference in fits. It quantifies the number of standard deviations the fitted value changes without the given study, Cook’s dist.: Cook’s distance depends on both the residual and leverage of the omitted study, Covariance ratio: the covariance ratio showing the change in the determinant of the covariance matrix of the effect size, Hat value: the value of the hat matrix without the given study. (JPG 226 KB)

Supplementary file 26 (DOCX 262 KB)^{(262.1KB, docx)}

Author contributions

BG: conceptualization, investigation, project administration, validation, formal analysis, visualization, and writing—original draft; AR: conceptualization, methodology, project administration, and writing—review and editing; JH: investigation, validation, data curation, writing—review and editing; BT: conceptualization and writing—review and editing; ZS: conceptualization and writing—review and editing; DSV: formal analysis, data curation, visualization, and writing—review and editing; PJH: conceptualization and writing—review and editing; NF: conceptualization and writing—review and editing; SZÁ: conceptualization and writing—review and editing; PH: supervision, funding acquisition, and writing—review and editing; IH: conceptualization, supervision, and writing—original draft. All authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript.

Funding

Funding was provided by the ÚNKP-22–3 New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund (to BT—ÚNKP-23–3-II-PTE-1996).

Data Availability

The data that support the findings of this study are available from the corresponding author, I.H., upon reasonable request.

Declarations

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent does not apply.

Conflict of interest

The authors declare no conflict of interests.

Footnotes

Key points

1. Previous data on different ERCP techniques for patients following RYGB were controversial, as more effective methods appeared to have higher complication rates.

2. Our study found that the chances of successful ERCP were significantly higher with laparoscopy-assisted and endoscopic ultrasound-directed techniques than with enteroscopy-assisted ERCP.

3. Based on our results, the three methods did not significantly differ in complication rates.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

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Supplementary file 26 (DOCX 262 KB)^{(262.1KB, docx)}

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, I.H., upon reasonable request.

[CR1] 1.Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery survey 2018: similarities and disparities among the 5 IFSO chapters. Obes Surg. 2021;31(5):1937–48. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR2] 2.Gostout CJ, Bender CE. Cholangiopancreatography, sphincterotomy, and common duct stone removal via Roux-en-Y limb enteroscopy. Gastroenterology. 1988;95(1):156–63. [DOI] [PubMed] [Google Scholar]

[CR3] 3.Gray R, Leong S, Marcon N, et al. Endoscopic retrograde cholangiography, sphincterotomy, and gallstone extraction via gastrostomy. Gastrointest Endosc. 1992;38(6):731–2. [DOI] [PubMed] [Google Scholar]

[CR4] 4.Baron TH, Vickers SM. Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Gastrointest Endosc. 1998;48(6):640–1. [DOI] [PubMed] [Google Scholar]

[CR5] 5.Kedia P, Sharaiha RZ, Kumta NA, et al. Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology. 2014;147(3):566–8. [DOI] [PubMed] [Google Scholar]

[CR6] 6.van der Merwe SW, van Wanrooij RLJ, Bronswijk M, et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022;54(2):185–205. [DOI] [PubMed] [Google Scholar]

[CR7] 7.Ayoub F, Brar TS, Banerjee D, et al. Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis. Endosc Int Open. 2020;8(3):E423–36. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR8] 8.Connell M, Sun WYL, Mocanu V, et al. Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis. Surg Endosc. 2022;36(9):6868–77. [DOI] [PubMed] [Google Scholar]

[CR9] 9.Dhindsa BS, Dhaliwal A, Mohan BP, et al. EDGE in Roux-en-Y gastric bypass: how does it compare to laparoscopy-assisted and balloon enteroscopy ERCP: a systematic review and meta-analysis. Endosc Int Open. 2020;8(2):E163–71. [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

Understanding the Role of Different ERCP Techniques in Post-Roux-en-Y Gastric Bypass Patients: a Systematic Review and Meta-analysis

Bálint Gellért

Anett Rancz

Jakub Hoferica

Brigitta Teutsch

Zoltán Sipos

Dániel S Veres

Péter Jenő Hegyi

Szabolcs Ábrahám

Péter Hegyi

István Hritz

Abstract

Graphical abstract

Supplementary Information

Introduction

Materials and Methods

Eligibility Criteria

Systematic Search

Selection Process

Data Collection

Data Items

Outcomes

Effect Measures

Synthesis Methods

Risk of bias (RoB)

Certainty Assessment

Results

Search and Selection

Fig. 1.

Baseline Characteristics

Table 1.

Meta-analysis

Primary Outcomes

Technical success

Fig. 2.

Clinical success

Fig. 3.

Secondary Outcomes

Overall early adverse event rate

Fig. 4.

Procedure-related and pooled perforations

Overall bleeding rate

Post-ERCP pancreatitis

Risk of bias Assessment

Publication bias

Sensitivity Analysis

Certainty of Evidence

Systematic Review

Acute Cholangitis

Mortality

Procedure Duration for EDGE

Length of Hospital Stay for EDGE

Length of Hospital Stay for EA-ERCP

Predictive Factors for Fistula Formation and the Risk of Weight Gain

Qualitative Assessment of Studies Not Suitable for Statistical Synthesis

Discussion

Technical and Clinical Success

Table 2.

Complications

Limitations

Strengths

Implications for the Future

Conclusion

Supplementary Information

Author contributions

Funding

Data Availability

Declarations

Ethical approval

Informed consent

Conflict of interest

Footnotes

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES