EUS-Directed Transenteric ERCP Expands Options in Surgically Altered Anatomy : Gastrointestinal Endoscopy | May 2026

Introduction

Biliary intervention in patients with surgically altered anatomy remains one of the most technically challenging areas in therapeutic endoscopy. Conventional enteroscopy-assisted ERCP is often limited by difficult limb access, prolonged procedure time and reduced cannulation success, particularly in Roux-en-Y reconstructions and hepaticojejunostomy anatomies. Therapeutic endoscopic ultrasound (EUS) has increasingly emerged as an alternative platform for creating transluminal access pathways in these complex settings.

Problem Statement

Although EUS-guided anastomosis using lumen-apposing metal stents (LAMS) has transformed access strategies in gastric bypass anatomy, evidence supporting EUS-directed transenteric ERCP (EDEE) in other surgically altered anatomies remains limited. Key concerns include procedural feasibility, adverse events, fistula persistence and the practical role of this technique compared with percutaneous or enteroscopy-assisted approaches.

Summary

This multicenter study demonstrates that EDEE using EUS-guided anastomosis with LAMS is a highly effective approach for biliary intervention in patients with complex surgically altered anatomy. The technique achieved excellent rates of EUS-guided anastomosis creation and high technical and clinical success for subsequent ERCP, even in anatomies traditionally considered extremely difficult for standard endoscopic access. Most procedures were performed for benign indications, particularly hepaticojejunostomy strictures requiring repeated interventions, highlighting one of the major advantages of EDEE: the ability to establish durable and repeatable endoscopic access to the biliary limb. The study also emphasizes the technical versatility of EDEE, with multiple strategies successfully used to identify the biliary limb depending on surgical configuration. Adverse events occurred in approximately one-fifth of patients, although severe complications were relatively uncommon and most LAMS-related events were managed endoscopically or conservatively. Persistent fistula formation after LAMS removal remained a notable issue, although its long-term clinical significance outside bariatric anatomy remains uncertain. Overall, the findings position EDEE as a major advancement in interventional endoscopy for surgically altered anatomy and support its role as a minimally invasive alternative to percutaneous drainage or surgery, particularly in benign disease requiring repeated biliary access.