Commentary on “Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS”

I read with great interest the paper by Tyberg et al. entitled, “Endoscopic Ultrasound (EUS)-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography or EUS: MidTerm Analysis of an Emerging Procedure,” published in this issue of Clinical Endoscopy. The authors reported results of what appears to be an evaluation of the efficacy and safety of the EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) technique. Technical success was achieved in all 16 patients, with the gastrogastric approach in 6 and the jejunogastric approach in 10. Moreover, 10 of 11 cases achieved clinical success; the other 5 cases were awaiting fistula maturation. In terms of adverse events, stent dislodgement occurred in 3 patients and jejunal perforation during sequential endoscopic retrograde cholangiopancreatography (ERCP) procedures occurred in 1 patient. The mean weight difference before and after the procedure, the authors’ greatest concern, was minimal. Finally, the authors concluded that the EDGE technique is an effective, minimally invasive, single-team, and often single-session solution to the difficulties associated with ERCP in patients who have undergone Rouxen-Y gastric bypass (RYGB). This technique is similar to EUS-guided gastrojejunostomy, with an approach to the proximal jejunum from the stomach under endosonographic guidance, and placement of an exclusive bi-flanged lumen-apposing metal stent (LAMS) along with the previously formed fistula tract. In the clinical setting, the major concern with this procedure is appropriate endosonographic positioning of the proximal jejunum because it is unclear which portion of the jejunum is being scanned. Similarly, identification of the safest point of the bypassed portion of the stomach (the excluded stomach in this article) is critical in the EDGE technique because this may not always maintain dilation sufficient for needle puncture. In addition to target identification, the choice of appropriate devices for the creation of the anastomosis (LAMS) appears to be another critical concern throughout the EDGE procedure. In this study, stent (AXIOSTM; Boston Scientific, Marlborough, MA, USA) dislodgement during the index procedure requiring second revision with additional stent placement occurred in three cases. To date, two representative LAMS implants, AXIOS and SPAXUS (TaeWoong Medical, Goyang, Korea), are commercially available for various EUS-guided transmural drainage and intervention such as necrosectomy. The flange of the AXIOS stent for prevention of stent migration and holding the tissue layers together is generally stronger than the SPAXUS stent. The AXIOS stent also has a larger flange diameter (21 or 24 mm) and lumen diameter (10 or 15 mm). Nevertheless, the SPAXUS stent has a considerable advantage because it is easier to deploy than the AXIOS stent. FurtherReceived: February 27, 2017 Accepted: March 3, 2017 Correspondence: Se Woo Park Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7 Keunjaebong-gil, Hwaseong 18450, Korea Tel: +82-31-8086-2858, Fax: +82-31-8086-2029, E-mail: britnepak@hallym.or. kr