A systematic review of technical factors associated with persistent fistula after endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y gastric bypass.
Review
Overview
abstract
BACKGROUND AND AIMS: An important unintended consequence of endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in patients with Roux-en-Y gastric bypass is persistent fistula (PF) formation after stent removal. To better inform procedural decision-making, we aimed to elucidate the technical factors associated with PF after EDGE. METHODS: We performed a systematic literature search of EMBASE, Scopus, and PubMed databases from inception until November 2024. Two authors independently extracted data on technical factors potentially associated with PF. Discrepancies were resolved by consensus. The association between PF and selected technical characteristics was evaluated. RESULTS: Of 398 patients who underwent objective testing after EDGE, 78 (19.6%) had PF. There did not appear to be an association between PF and location of the fistula (gastro-gastric vs jejuno-gastric) (RR 1.16, 95%CI 0.93-1.41, p=0.14) or whether ERCP was performed at the time of fistula creation or later (RR 1.03, 95%CI 0.66-1.70, p=0.99). The use of a larger lumen apposing metallic stent (20 mm vs. 15 mm) did appear associated with PF (RR 1.65, 95%CI 1.02-2.72, p=0.022). Passive (spontaneous) fistula closure after stent removal was also associated with PF formation relative to active closure (RR 7.25, 95%CI 1.08-192.5, p=0.020). The association between stent dwell time and PF was not statistically significant according to the Wilcoxon signed rank sum test (p=0.13) but was significant by the weighted paired t-test (p=0.04). CONCLUSIONS: In this systematic review, larger stent size, passive (spontaneous) closure after stent removal, and longer stent dwell time appeared associated with an increased risk of PF formation after EDGE.
