S2176 Intraprocedural Real-Time Predictors of Failure in Patients With Roux-en-Y Gastric Bypass Undergoing Double-Balloon Assisted ERCP: Is There an Optimal Time to Cross-Over to EUS-Directed Transgastric ERCP?

Introduction: Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BEA-ERCP) is a common approach for managing pancreaticobiliary disease in patients with Roux-en-Y gastric bypass (RYGB). Our study aimed to identify intraprocedural predictors of BEA-ERCP failure and determine the optimal timing for cross-over to endoscopic ultrasound-directed transgastric ERCP (EDGE) during the same session. Methods: We prospectively evaluated consecutive RYGB patients undergoing BEA-ERCP from 2021 to 2024. Procedure-related data was collected prospectively, and patients were divided into 2 cohorts based on procedure outcome: patients with successful versus failed BEA-ERCP. Binary logistic regression analyses were conducted to identify intraprocedural predictors of BEA-ERCP failure. Receiver operating characteristic (ROC) curves were used to determine the optimal timing for cross-over to EDGE. Results: Forty-two patients (11 men, 31 women) underwent BEA-ERCP with a success rate of 73.8% (n = 31). Significant risk factors of BEA-ERCP failure included excessive resistance to scope advancement (P < 0.0001), failure to reach the ampulla (P < 0.0001), patient position (P = 0.009), BMI (P = 0.004) and time to reach the jejuno-jejunal (J-J) anastomosis (P < 0.0001). Binary logistic regression analysis identified time to reach the J-J anastomosis ≥23 minutes (OR 1.360 [95% CI: 1.079-1.713], P = 0.009), excess resistance to scope advancement (OR 2.223 [95% CI: 2.001-4.167]) and failure to reach ampulla (OR 9.929 [95% CI: 2.004-4.033]) as the statistically significant predictors of BEA-ERCP failure. When there were ≥2 predictors of BA-ERCP failure, the likelihood of having failed BA-ERCP was 2.370 with 95.50% sensitivity and 90% specificity with AUC = 0.929 (P = 0.0001). Conclusion: Time to reach the J-J anastomosis of ≥23 minutes, excess resistance to scope advancement, and failure to reach the ampulla are significant predictors of BEA-ERCP failure. When there were ≥2 predictors of BA-ERCP failure present, it represents an optimal time to cross over to EDGE. These findings can guide clinical decision-making and improve procedural outcomes. At our institution, after obtaining consent for both BAE-ERCP and EDGE, all patients with uncomplicated pancreaticobiliary disease undergo BAE-ERCP first. If the J-J is not reached within 23 minutes, endoscopist is experiencing excessive scope resistance and/or ampulla is not reached altogether, an early decision is made to cross over to EDGE.