By Jane Ehrhardt
In 2021, an estimated 262,893 bariatric surgeries were performed in the U.S., according to the American Society for Metabolic and Bariatric Surgery. That represents a rise of nearly 60 percent over the previous decade.
One downside to the Roux-en-Y gastric bypass (RYGB) is that it leaves patients with limited options for accessing portions of their digestive tract when issues arise, such as blockages and cancers. “After bariatric surgery, their anatomy is altered,” says Mohannad Dugum, MD, gastroenterologist and advanced endoscopist at Gastro Health - Grandview Medical Center. “Areas that we reach easily via routine endoscopy before bypass surgery are now difficult to access, if we can reach them at all.”
In the gastric bypass, a small stomach pouch is created and attached via its own branch to the small intestine. This leaves the remainder of the stomach and its natural attachment to the intestines intact, but literally bypassed in the digestive process.
It also cuts off the usual endoscopic route from the mouth through the stomach to the bile ducts and the pancreas. Instead, reaching those areas for even biopsies can require surgery or a much longer and less effective path through the pouch into the small intestine and back through the stomach to the common bile duct.
EDGE (endoscopic ultrasound-directed transgastric ERCP) temporarily recreates that original route. Using only endoscopy, a large stent is placed between the stomach pouch and the excluded stomach, which reverses the gastric bypass. Then surgeons can go through that stent like they do through the normal stomach to reach areas they need to reach without any surgery or external incisions.
The wide, but short, stent gets inserted two weeks ahead of any procedure. “In that time, the track heals up nicely, so it almost becomes a natural part of the body,” Dugum says. After the procedure, the stent can be left in to retain that access route for as long as needed. When the stent is removed, the hole generally closes on its own.
About 15 percent of the holes remain open, according to one clinical trial of 1,000 patients. In those cases, the hole can be stitched or clipped shut in a 15 to 30 minute procedure, if the patient wants. There is no notable downside to leaving the very small hole open except the possibility of weight gain via food passing into the original stomach versus only through the stomach pouch. Considering most EDGE patients are elderly, Dugum generally recommends closing it only if digestion issues have arisen or the patient is very concerned about their weight gain.
Surprisingly, the EDGE procedure requires no new technology. Neither the scope nor the metal stent are new. The endoscopic ultrasound scope has been in use since the 1980s. “The innovation is in how we’re using them,” Dugum says.
EDGE patients mainly face issues in the bile ducts and pancreas, such as with cysts, masses, leaks, and stones. Bile duct stones top the list. However, the versatility created with the stent access can fulfill multiple needs in one non-surgical procedure in situations as serious as potential pancreatic cancer. “If the drainage from the liver is impaired, we can get biopsies and confirm if it’s cancer, place a stent to relieve the blockage, make the patient feel better, and get them on to the next step of their treatment, without surgery or a hospital stay” Dugum says.
The stent-based procedure offers applications beyond gastric bypass patients, as well. “As an extension of EDGE, we can place stents between different parts of the GI tract, and not just for access,” Dugum says. “For instance, if a blockage forms in the small intestine due to cancer closing down the stomach and preventing a patient from eating, we can use the same technology to place a large stent between the stomach and another loop of the small intestine beyond the blockage.
Dugum performed Grandview’s first EDGE procedure in August. “It’s very innovative and it’s satisfying doing something high impact in a relativity quick procedure in the GI lab,” he says. “We don’t have to involve other teams or the OR, and the expense is much better for the patient and the healthcare system. Patients like to avoid surgery, and you produce a huge impact for them.”