Systematic review of technical factors associated with persistent fistula after EUS-directed transgastric ERCP in patients with Roux-en-Y gastric bypass.

BACKGROUND AND AIMS

An important unintended consequence of EUS-directed transgastric ERCP (EDGE) in patients with Roux-en-Y gastric bypass is persistent fistula (PF) formation after stent removal. To better inform procedural decision-making, we wanted 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 (gastrogastric vs jejunogastric) (relative risk, 1.16; 95% CI, 0.93-1.41; P = .14) or whether ERCP was performed at the time of fistula creation or later (relative risk, 1.03; 95% CI, 0.66-1.70; P = .99). The use of a larger lumen-apposing metal stent (20 mm vs 15 mm) did appear to be associated with PF (relative risk, 1.65; 95% CI, 1.02-2.72; P = .022). Passive (spontaneous) fistula closure after stent removal was also associated with PF formation relative to active closure (relative risk, 7.25; 95% CI, 1.08-192.5; P = .020). The association between stent dwell time and PF was not statistically significant according to the Wilcoxon signed rank sum test (P = .13) but was significant by the weighted paired t test (P = .04).

CONCLUSIONS

In this systematic review, larger stent size, passive (spontaneous) closure after stent removal, and longer stent dwell time appeared to be associated with an increased risk of PF formation after EDGE.