The Emerging Role of Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE)

Purpose of review Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric operations, but it is associated with a high rate of gallstone-related complications. Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred therapeutic modality to treat choledocholithiasis; however, biliary access is compromised due to altered surgical anatomy after RYGB. Endoscopic ultrasound-guided transgastric ERCP (EDGE) is a recent endoscopic procedure developed to overcome this limitation. In this review, we discuss the recent literature surrounding technical and clinical considerations of the EDGE procedure and its prospects. Recent findings The EDGE procedure has high technical and clinical success rates in the management of choledocholithiasis after RYGB. Long-term side effects related to the site of fistula creation, particularly weight regain and persistent fistula, are worrisome and require careful consideration during the procedure planning. As the procedure gains momentum, the scope of interventions has expanded to include several other indications beyond ERCP. Summary EDGE is a safe and cost-effective endoscopic treatment modality in patients who have had RYGB. It has a higher technical success rate than device-assisted enteroscopy and comparable rate to laparoscopic-assisted ERCP with lower rate of adverse events. In expert hands and with proper patient selection, EDGE can save patients from more invasive interventions and decrease the burden on the healthcare system.