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Page 10 of 13 Castro et al. Mini-invasive Surg 2020;4:47 I http://dx.doi.org/10.20517/2574-1225.2020.14

Cholelithiasis in bariatrics
Up to 30% of patients may develop gallstones 24 months after bariatric surgery if associated with significant
weight loss. The altered anatomy following bariatric surgery poses a challenge for the management of
cholelithiasis. The preferred approach in these situations is laparoscopy-assisted endoscopic retrograde
[65]
cholangiopancreatography (LA-ERCP) . However, this therapy requires multiple specialty team
participation which may sometimes complicate the scenario. For this matter, a new endoscopic therapy was
developed and can be performed by a single team with the use of an endoscopic ultrasound (EUS). The
EUS-guided transgastric ERCP (EDGE) requires accessing the excluded stomach from the gastric pouch
and creating a gastrogastric or jejunogastric fistula by using a lumen-apposing metal stent, after which a
[65]
conventional ERCP is performed [65,66] . Kedia et al. compared technical and clinical outcomes of EDGE
and LA-ERCP in post-RYGB patients. The success rate for therapeutic ERCP was achieved in 96.5% and
97.7% for each group, respectively. The adverse event rate reported was 24% (7/29) for the EDGE group and
19% (8/43) for the LA-ERCP group. The events included perforation, pancreatitis, stent dislodgement, and
[66]
bleeding; similar to those reported by Tyberg et al. . A multicenter experience using EDGE procedure
demonstrated that it can be safely and effectively applied in postbariatric patients with biliary disease.
Although both these studies have shown positive outcomes, prospective studies are needed to confirm its
effectiveness and outcomes.

CONCLUSION
Minimally invasive techniques have progressed significantly over the past years. Management of obesity
continues to expand, and multiple devices are now available to address these patients. Most of the
endoscopic procedures mentioned have demonstrated positive outcomes with an adequate safety profile;
nonetheless, there is still an opportunity for device improvement as well as physician expertise. It is of utter
importance that bariatric surgeons are dexterous with the endoscope as it is a crucial tool to manage obese
patients, not only as an adjuvant but also as a primary procedure. The utility of endoscopy for management
in the obese population has increased substantially among our practice. We believe that the endoscopic
approach in bariatrics is an appealing alternative to consider as first-line therapy. While there is still a need
for long-term results and further progress, these new endoscopic techniques provide promising alternatives
in the management for obesity.

DECLARATIONS
Authors’ contributions
Made a substantial contribution to conception, design of the study, performed data analysis, and
interpretation: Castro M, Guerron AD

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Dr. A. Daniel Guerron disclosed a financial relationship with Levita, Phenomix, Gore, Medtronic, and
Biom’up. Dr. Castro declared that there is no conflict of interest.

Ethical approval and consent to participate
Not applicable.