Introduction:
Altered anatomy from surgical interventions poses unique challenges in the management of biliary diseases. Accessing the biliary tree becomes a complex task, often requiring either Percutaneous Transhepatic Cholangipgram (PTC) with Cholangioscopy (PTCwC) or Endoscopic Ultrasound-Directed Transgastric/Transenteric Endoscopic Retrograde Cholangiopancreatography (EDGE/EDEE).

Methods:
We conducted a retrospective single-center study at a tertiary health care system. Patients who are older than 18 years of age, with known prior gastric surgery/altered anatomy, who underwent EDGE/EDGI or PTCwC between 1/2015 - 11/2023 were included. Data on baseline characteristics, surgery type, comorbidities, intervention type and characteristics, imaging findings, clinical outcomes, and complications were collected.

Results:
A total of 33 patients were included, 26 (78.8%) were females, and 29 (87.9%) had Roux-En-Y gastric bypass, 2 had duodenal switch, 1 had Billroth II, and 1 had esophagojejunostomy. 14 patients underwent PTCwC with mean age (66.4 years, SD 12) and 19 patients underwent EDGE/EDEE procedure with mean age (68.7, SD 11.2). 8 (24.2%) patients presented with sepsis, 6 of them had overt cholangitis, 20 (60.1%) patients presented with choledocholithiasis, and rest presented with jaundice secondary to biliary strictures (benign and malignant). All patients who underwent PTCwC were successful in achieving adequate drainage and therapeutic intervention (100%). 18 out of 19 (94.7%) patients who underwent EDGE/EDEE achieved adequate drainage with sphincterotomies and stent placement but 1 case was unsuccessful for failure of ampullary cannulation requiring PTC placement and cholangioscopy. 11 (57.9%) were single-stage EDGE. 3 moderate adverse events were noted in the EDGE/EDEE procedure, including 2 cases of LAMS misplacement initially with successful reattempt and one post-ERCP pancreatitis that was managed with supportive management, while 1 case of bile leakage around PTC site (7.1%) occurred in PTCwC group on initial placement. Adverse events between the groups were not statistically significant (P=1). Patients in the EDGE/EDEE group required significantly more ERCP sessions compared to PTCwC (3.2 ± 1.7 SD 1.7 vs. 1.8 ±1.3, SD1.3) p=0.007). However, when the total number of PTC exchange interventions were included, patients who underwent EDGE/EDEE required fewer procedures overall (3.2 ± 1.7 vs. 6.0 ± 2.7, p= 0.001).

Conclusion:
Our study suggests that the overall efficacy and safety of EDGE/EDEE compared to PTCwC is similar. EDGE/EDEE may offer a fewer number of total procedures compared to PTCwC, however, a larger scale randomized controlled trial is needed to compare efficacy and complications. The availability of expertise and resources remain critically important in determining the optimal approach.

Statistical analysis comparing EDGE/EDEE vs. PTC with Cholangioscopy outcomes.

Mark Obri

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