Current status and further directions of endoscopic ultrasound-directed transgastric ERCP and endoscopic ultrasound-directed transenteric ERCP in the management of pancreaticobiliary diseases in surgically altered anatomy: a comprehensive review

Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and endoscopic ultrasound-directed transenteric endoscopic retrograde cholangiopancreatography (EDEE) are innovative endoscopic techniques developed to overcome the challenges of biliary access in patients with surgically altered gastrointestinal anatomy. EDGE facilitates the creation of a gastro-gastric anastomosis, enabling endoscopic access to the excluded stomach and subsequent duodenum for endoscopic retrograde cholangiopancreatography (ERCP) procedures. Similarly, EDEE involves creating a gastro-jejunal anastomosis, allowing endoscopic access to the jejunum and hepaticojejunostomy for ERCP. These procedures are primarily indicated for patients with Roux-en-Y gastric bypass or other complex gastrointestinal surgeries that render traditional ERCP unfeasible. The major advantages of EDGE and EDEE include minimally invasive access to the biliary system, reduced procedural morbidity, and the ability to perform complex biliary interventions without additional surgeries. Using lumen-apposing metal stents in these procedures has further improved their safety and efficacy. This comprehensive review delves into EDGE and EDEE's technical nuances, clinical outcomes, and safety profiles. Our extensive literature searches reveal high procedural success rates and low complication incidences, establishing these methods as viable alternatives to traditional surgical and percutaneous approaches. We also discuss recent technological advancements, including developing enhanced stents and endoscopic ultrasound-guided instruments, which have refined these techniques and expanded their applications. Moreover, the review examines the integration of EDGE and EDEE with other therapeutic modalities, such as cholangioscopy and intraductal lithotripsy, to optimize treatment outcomes. Future directions emphasize the need for larger, multicenter trials to validate these findings further and create standardized protocols to ensure consistent procedural efficacy and safety. This review highlights the transformative potential of EDGE and EDEE in therapeutic endoscopy, advocating for their broader adoption in clinical practice and ongoing innovation in this rapidly evolving field.