Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE): Techniques, Outcomes and Safety Profiles

Patients with Roux-en-Y gastric bypass (RYGB) are a significant challenge for endoscopic retrograde cholangiopancreatography (ERCP) due to the altered anatomy. Endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) has emerged as a valuable alternative to standard methods like enteroscopy-assisted (EA-ERCP) and laparoscopy-assisted (LA-ERCP) ERCP. EDGE involves creating a temporary fistula between the gastric pouch and the excluded stomach under EUS guidance, typically using a lumen-apposing metal stent (LAMS). This allows a standard ERCP scope to access the second duodenum and the biliary tree with standard devices. Several studies have investigated the efficacy and safety of this approach, with variations in techniques such as suturing the LAMS to prevent migration. EDGE has demonstrated high technical success rates, and current evidence indicates that it can be performed safely, with acceptable rates of adverse events such as stent migration, bleeding, and perforation, making it the preferred option in referral centers. This comprehensive review aims to provide a concise evaluation of EDGE, its techniques, outcomes, and role in managing biliary and pancreatic disorders in RYGB patients.