Endoscopic ultrasound-directed transenteric ERCP (EDEE) in patients with postsurgical anatomy – novel but challenging

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with postsurgical upper gastrointestinal anatomy and enteroscopy-guided ERCP (e-ERCP) is utilized in most of these patients for biliary access [1]. Procedural success is suboptimal, especially in patients with Roux-en-Y anatomy. In patients with a Roux-en-Y gastric bypass (RYGB), we use EUS-directed transgastric ERCP (EDGE) for access into the excluded stomach and subsequent ERCP using standard duodenoscopes and equipment [2]. Nonetheless, the EDGE procedure remains controversial because of the potential risk of a permanent gastro-gastric fistula. In our experience, this risk is very low but data are needed to confirm the long-term safety of EDGE [2].