Based on this meta-analysis, the technical and clinical success rates between EUS-AG and BE-ERCP were comparable, including the incidence of pancreatitis, perforation, and bile leak in both techniques, suggesting a comparable safety profile. However, it is noteworthy that the overall rate of side effects was found to be higher in the BE-ERCP group when compared to the EUS-AG group. This observation may influence the choice of technique, favoring EUS-AG over BE-ERCP for its potentially lower risk of adverse effects. To the best of our knowledge, this study represents the first systematic review and meta-analysis to compare EUS-AG and BE-ERCP specifically in the context of RYGB patients.
ERCP in patients with surgically altered anatomy is difficult and requires an experienced endoscopist, a good understanding of the length of afferent limb, type of endoscope used with choice of approach and compatible ERCP accessories with various endoscopic types.15
Device assisted enteroscopy (DAE) procedures are currently considered first-line approach for patients with Roux en Y anatomy because of lower costs and risks compared to surgery.16 DAE can be performed with BE-ERCP or spiral enteroscopy. Recently, alternative access techniques have been gaining significance to improve efficacy and success rates including LA-ERCP and EDGE. Studies report LA-ERCP and EDGE are associated with higher technical, cannulation and therapeutic success compared to enteroscopy assisted ERCP, though they also have more adverse events compared to enteroscopy assisted ERCP.17
The core of our findings indicates that there is no significant difference in the technical and clinical success rates between EUS-AG and BE-ERCP. This outcome suggests that both techniques are equally viable options for endoscopic intervention in RYGB, allowing for flexibility in clinical decision-making based on the practitioner's expertise and the specific circumstances of each case.12–14 Itoi et al. report a technical success rate of 60% with EUS-AG technique in a recent case series of patients with surgically altered anatomy and choledocholithiasis.18 Iwashita et al. also reported the results of a prospective study of antegrade stenting in twenty patients with surgically altered anatomy. In their study, the technical and clinical success rates of EUS-AG treatment were both 95%.19
Our meta analysis showed a higher overall adverse event rate in the BE-ERCP group as compared to EUS-AG and our results are on par with what has been reported in the literature. A recent retrospective analysis by Gerson et al. Demonstrated that double balloon enteroscopy is associated with a higher complication rate compared with standard endoscopic procedures. The perforation rate was significantly elevated in patients with altered surgical anatomy undergoing diagnostic retrograde double balloon enteroscopy procedures.20 Inamdar et al. also report an overall 32 adverse events majorly due to pancreatitis, bleeding, perforation, and death from embolic stroke.21 Sato et al. also report aspiration pneumonia in 4 patients, respiratory failure in 2 patients, pulmonary embolism in 1 and bradycardia in 1 patient in BE-ERCP patients compared to none of these adverse effects in EUS-AG patients.13 Differences in the pooled safety of these procedures is a key finding of this study.
We do acknowledge the limitations associated with our study. First, the sample size is small with only 795 patients. No RCTs were available comparing EUS-AG and BE-ERCP, and our results were based on observational studies with their inherent bias. Hence, we advocate for the need for high-quality RCTs comparing both techniques in terms of their efficacy, risks, and complications. Third, due to the low number of full studies reporting all possible adverse effects, we cannot fully comprehend adverse effects profile for each procedure. Fourth, the experience of endoscopists cannot be disregarded. Lastly, the procedures were performed in high volume tertiary centers limiting generalizability. However, despite these limitations we performed a robust systematic review with stringent inclusion and exclusion criteria. Moreover, being the only meta-analysis in this topic, the findings of this study adds valuable information to the current literature.