Double-balloon enteroscopy application in biliary tract disease-its therapeutic and diagnostic functions

Biliary Cannulation in Patients with Roux-en-Y Gastrectomy: An Analysis of the Factors Associated with Successful Cannulation

Objective We investigated the results of biliary cannulation using a short-type single-balloon enteroscope in patients with a native papilla who had previously undergone Roux-en-Y gastrectomy and analyzed the factors associated with successful cannulation. Methods The study subjects consisted of patients with a native papilla who had previously undergone Roux-en-Y gastrectomy and endoscopic retrograde cholangiopancreatography using a short-type single-balloon enteroscope at our institution between September 2011 and July 2019. We carried out a retrospective investigation of the outcomes, including assessing the success rate of biliary cannulation, and analyzed the factors associated with successful cannulation. Results In total, 78 patients underwent biliary cannulation of a native papilla. The success rate of biliary cannulation was 80.8% (88.5% when including success on repeated attempts). The success rate of the standard cannulation technique was 60.3%, with the use of advanced cannulation techniques to secure the pancreatic duct providing the same additional effect as a normal anatomy. Adverse events occurred in 9.0% of cases. A multivariate analysis of the Roux-en-Y gastrectomy patients found that cannulation was more likely to be successful in patients in whom the scope could be placed in the retroflex position (odds ratio: 7.88, 95% confidence interval: 2.19-37.77, p<0.001). Conclusion Selective biliary cannulation using a short-type single-balloon enteroscope in patients with a native papilla who had undergone Roux-en-Y gastrectomy was effective and safe. The retroflex position provided a good papilla field of view and improved the success rate of biliary cannulation.

Analysis of the factors involved in procedural failure: Endoscopic retrograde cholangiopancreatography using a short-type single-balloon enteroscope for patients with surgically altered gastrointestinal anatomy

AIM

To analyze factors involved in procedural failure and to discuss responses to procedural failure by using the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) carried out using a short-type single-balloon enteroscope (short SBE) in patients with surgically altered gastrointestinal anatomy.

METHODS

The study sample included patients who underwent ERCP-related procedures using a short SBE between September 2011 and September 2018 at our hospital. Outcomes, including procedural success rate, were studied retrospectively to analyze the factors involved in procedural failure.

RESULTS

Analysis included 191 procedures carried out in 121 patients. Procedural success rate was 85.9% with an adverse event rate of 8.4%. Causes of procedural failure included malignant biliary obstruction (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.19-7.25, P = 0.02), first ERCP attempt (OR: 5.32, 95% CI: 1.30-36.30, P = 0.02), and Roux-en-Y reconstruction (OR: 0.08, 95% CI: 0.004-0.39, P < 0.001). With regard to the response to failure, in cases of malignant biliary obstruction, reattempted short SBE-assisted ERCP was difficult because of invasion of the small intestine or papilla. A large number of these cases required alternative treatment (10 of 15 cases, 66.7%) using percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided biliary drainage (EUS-BD).

CONCLUSION

Endoscopic retrograde cholangiopancreatography using a short SBE is safe and effective, with malignant biliary obstruction being a specific cause of failure. Technical proficiency with different modalities, such as PTBD and EUS-BD, is necessary to respond to failure in these cases.

Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography: Preliminary experience and technique description

INTRODUCTION

Common bile duct lithiasis after Roux-en-Y gastric bypass (RYGB) or upper gastrointestinal stenosis has become a challenging problem nowadays, especially as obesity surgery is increasing. In this study, we assess the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) and describe its technique.

METHODS

A retrospective review of a prospectively collected database of consecutive patients undergoing a LAERCP between February 2014 and May 2015 was performed at a single institution. Indications were common bile duct lithiasis associated with acute or past episodes of cholangitis and pancreatitis. Endoscopic access to the gastric remnant was obtained laparoscopically.

RESULTS

In total 5 cases were identified. Four of them had undergone a RYGB and one of them presented a benign esophageal peptic stenosis, not allowing peroral gastric access. Biliary cannulation using LAERCP associated with sphincterotomy and stone extraction was successfully achieved in all patients. Mean duration of the entire procedure was 134minutes (range: 66-200min). No early major complications were observed and the mean postoperative hospital stay was 4 days (range: 2-5 days).

CONCLUSIONS

LAERCP is a safe and successful procedure for the treatment of common bile duct lithiasis when conventional biliary access is not feasible, notably after RYGB. Larger trials still need to be performed to evaluate efficacy, technical success, and complications related to this technique.

Performance of a new short-type double-balloon endoscope with advanced force transmission and adaptive bending for pancreaticobiliary intervention in patients with surgically altered anatomy: A propensity-matched analysis

BACKGROUND AND AIM

A new short-type double-balloon endoscope (DBE) has been developed with a major focus on facilitating scope insertion to the target site for pancreaticobiliary interventions in patients with surgically altered anatomy. We investigated the performance of this new short-type DBE by comparing it with a conventional DBE.

METHODS

Data from 885 endoscopic retrograde cholangiopancreatography (ERCP) procedures using balloon endoscopy were analyzed. We used propensity score matching to adjust for differences between patients who underwent ERCP procedures using the new short-type DBE versus the conventional short-type DBE.

RESULTS

A total of 163 pairs of patients were selected by propensity score matching. Success rate of reaching the target site was 100% in both the new DBE group and the conventional DBE group (P = 1.0). The new DBE group had a shorter insertion time required to reach the target site than the conventional DBE group (10 min vs. 14 min, P < 0.01). Success rate of pancreaticobiliary interventions in the new DBE group was as high as that in the conventional DBE group (92% vs. 89% P = 0.35). Overall procedure time decreased from 62 min in the conventional DBE group to 55 min in the new DBE group (P = 0.26). No significant differences in the rates of adverse events were observed between the two groups.

CONCLUSION

A new short-type DBE allows faster insertion to the target site for pancreaticobiliary intervention in patients with surgically altered anatomy.

Usefulness of the "newly designed" short-type single-balloon enteroscope for ERCP in patients with Roux-en-Y gastrectomy: a pilot study

Background and aims  In recent years, the short single-balloon enteroscope (SBE) has been used during endoscopic retrograde cholangiopancreatography (ERCP) for patients with surgically altered anatomy and has been reported to be useful. However, difficulties remain, and the procedures and devices need improvements. We assessed the usefulness and superiority of a new short SBE equipped with passive bending and high-force transmission by comparisons with outcomes using the conventional short SBE. Methods  This study evaluated short SBE-assisted ERCP-related procedures for Roux-en-Y gastrectomy between September 2011 and October 2017. Outcomes including the procedural success rate, which was the primary outcome, were assessed to compare the conventional short SBE (SIF-Y0004 [prototype]) and the new short SBE (SIF-H290S). Results  Of 74 procedures performed in 61 patients, 51 procedures in 39 patients involved the SIF-Y0004, and 23 procedures in 22 patients involved the SIF-H290S. The procedural success rates were 70.6 % for SIF-Y0004, and 95.7 % for SIF-H290S, representing better results for the new short SBE ( P  = 0.02). The new short SBE also had a superior diagnostic success rate ( P  = 0.047) and median time to reach the blind end ( P  < 0.001). Conclusions  Roux-en-Y gastrectomy patients treated with the new short SBE had better outcomes than those treated with conventional short SBE. More cases need to be studied; however, the new short SBE has the potential to improve ERCP outcomes in patients with surgically altered anatomy.

Diagnostic and Therapeutic Endoscopic Retrograde Cholangiography Using a Short-Type Double-Balloon Endoscope in Patients With Altered Gastrointestinal Anatomy: A Multicenter Prospective Study in Japan

OBJECTIVES

To evaluate the utility and safety of a short-type double-balloon endoscope (DBE) in the treatment of biliary disease in patients with surgically altered gastrointestinal (GI) anatomy.

METHODS

This study was conducted as a multicenter, single-arm, prospective trial at five tertiary academic care centers and three community-based hospitals in Japan. Consecutive patients with biliary disease with altered GI anatomy were prospectively included in this study.

RESULTS

A total of 311 patients underwent double-balloon endoscopic retrograde cholangiography (ERC). The success rate of reaching the target site, the primary end point, was 97.7% (95% confidence interval (CI): 95.4-99.1). The success rate of biliary cannulation and contrast injection of the targeted duct, the secondary end point, was 96.4% (95% CI: 93.6-98.2), and the therapeutic success rate was 97.9% (95% CI: 95.4-99.2). Adverse events occurred in 33 patients (10.6%, 95% CI: 7.1-14.0) and were managed conservatively in all patients with the exception of 1 in whom a perforation developed, requiring emergency surgery.

CONCLUSIONS

ERC using a short-type DBE resulted in an excellent therapeutic success rate and a low rate of adverse events. This treatment can be a first-line treatment for biliary disease in patients with surgically altered GI anatomy.

Endoscopic Retrograde Cholangiopancreatography in Post Gastrectomy Patients

Endoscopic retrograde cholangiopancreatography (ERCP) in post-gastrectomy patients with Billroth II (BII) reconstruction and Roux-en-Y (RY) reconstruction presents a challenge to therapeutic endoscopists. Major difficulties, including intubation to the ampulla of Vater, selective cannulation, and ampullary intervention, must be overcome in these patients. Recent data have shown that device-assisted ERCP allows for high success rates in these patients because various devices are useful for overcoming major difficulties. Therefore, good knowledge of postoperative anatomy and various devices is mandatory before performing ERCP procedures for post-gastrectomy patients.

Feasibility of cap-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy.

Methods

The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope.

Results

The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths.

Conclusions

Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.

Advances in balloon endoscopes

In September 2003, a double-balloon endoscope (DBE) composed of balloons attached to a scope and an overtube was released in Japan prior to becoming available in other parts of the world. The DBE was developed by Dr. Yamamoto (1), and 5 different types of scopes with different uses have already been marketed. In April 2007, a single-balloon small intestinal endoscope was released with a balloon attached only to the overtube as a subsequent model. This article presents a detailed account of the development of these scopes up to the present time.

Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy

The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.

Role of endoscopy in the bariatric surgery of patients

Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett’s esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett’s esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography in patients with surgically altered anatomy: higher failure rate in malignant biliary obstruction - a prospective single center cohort analysis

INTRODUCTION

The performance of endoscopic retrograde cholangiopancreaticography (ERCP) in patients with post-surgically altered anatomy is technically ambitious. Our study aimed at comparing a cohort of patients having successfully undergone single-balloon enteroscopy (SBE)-assisted ERCP to those in whom SBE-ERCP failed.

METHODS

This trial is a prospective single center cohort study. Participants included 30 patients (median age 69.5 years, range 20-86 years) with previous pancreaticobiliary surgery. First, a conventional ERCP approach was attempted in all patients. Additionally, those patients in whom prior conventional ERCP had failed underwent SBE-ERCP (n = 26). Patients' baseline characteristics were retrieved and patient cohorts with and without successful SBE-ERCPs were compared and analyzed. Statistical analysis was applied. Univariate analysis was performed to detect possible risk factors of SBE-ERCP failure.

RESULTS

The overall success rate of SBE-ERCP, including two patients with percutaneous transhepatic cholangiography- assisted rendezvous technique was 65.4% (17/26). Patients with malignant obstructive cholestasis had a significantly higher failure rate compared to those with benign strictures (84.2% vs. 14.2%, p < 0.001).

DISCUSSION

SBE-ERCP is a promising tool for diagnostic and therapeutic procedures in the pancreaticobiliary system of selected, previously operated patients with failure of conventional ERCP. However, higher failure rates in malignant biliary obstruction should be taken into account.

The use of double balloon enteroscopy for diagnosis and treatment of strictures of hepaticojejunal anastomoses after primary correction of bile duct injuries

INTRODUCTION

Development of strictures of hepaticojejunal anastomoses (HJA) is observed in 6-30% of patients and mortality after repeated reconstructive interventions ranges from 13% to 25%. Double balloon enteroscopy (DBE) allows one to visualize the zone of Roux-en-Y anastomosis after reconstructive operations on the bile ducts for differentiation between stricture of HJA and recurrent cholangitis.

AIM

Report on the first experience of DBE of jejunal loop studies after reconstructive operations on the biliary tract.

MATERIAL AND METHODS

During the period 2002-2012 we performed in our centre 86 hepaticojejunostomies after iatrogenic bile duct injuries. Mean age was 51 ±6 years. Patients with Roux-en-Y HJA and jejunum loop with Braun's bypass anastomosis who underwent DBE with endoscopic retrograde cholangiography (DBE-RChG) in our unit between February 2009 and December 2012 were enrolled in this study. A total of 33 procedures were performed during this period. All of them involved examination of HJA through a jejunum loop by DBE with capture of bile for bacteriology, Roux loop wall for biopsy and miniinvasive procedures.

RESULTS

The DBE-RChG after visualization of the HJA zone was performed in 21 cases: 3 of them had the jejunum loop to Braun's bypass, 18 - HJA on the Roux loop. In 13 cases stricture of HJA was confirmed: at 6 reoperations were performed, in 7 - miniinvasive procedures (3 - laser vaporizations, 2 - stone extraction, 1 - lithotripsy, 1 - at the first stage stone extraction was carried out, then laser vaporization). The DBE-RChG was performed in 13 (61.9%) patients. The overall diagnostic success with Braun's bypass was 100%, after Roux-en-Y reconstruction in 10 of 13 cases (55.6%). In connection with accumulation of experience, in 2012 diagnostic success in DBE-RChG of HJA on Roux loop increased to 81.3%.

CONCLUSIONS

The MRI-ChG in our series frequently (10.3%) shows a false-positive result in favor of HJA strictures. The DBE examination of HJA with additional cholangiography is a modern and precise method of detection of HJA strictures. Their DBE-balloon dilation and argon-laser vaporization or DBE lithoextraction are new ways of miniinvasive treatment.

Endoscopic bile duct and/or pancreatic duct cannulation technique for patients with surgically altered gastrointestinal anatomy

There are two major hurdles to carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal anatomy (Billroth II gastrectomy [B-II], Roux-en-Y anastomosis [R-Y] etc.), post-pancreatoduodenectomy or post-choledochojejunostomy. These are: (i) the endoscopic approach to the afferent loop, blind end, and the site of bilio-pancreatic anastomosis; and (ii) bile duct and/or pancreatic duct cannulation. Balloon-assisted enteroscopy (BAE) became available in recent years and is now being actively used to overcome the first hurdle and, at least, the success rate has improved. However, room for improvement still remains in regards to the second hurdle (i.e. the success rate of cannulation of the bile duct and/or pancreatic duct), and there has been a desire for the development of dedicated devices (ERCP catheters, hoods etc.) and for improvement in the functionality of the enteroscopes etc. In the present review, we explain the basic procedure for bile duct and/or pancreatic duct cannulation with conventional endoscopes and BAE, and modifications of the basic procedure.

Evaluation of endoscopic retrograde cholangiopancreatography using a newly developed short-type single-balloon endoscope in patients with altered gastrointestinal anatomy

BACKGROUND AND AIM

Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy had been impractical until the development of balloon-assisted endoscope (BAE) made it feasible. The aim of the present study was to evaluate the usefulness of a newly developed short-type single-balloon endoscope (s-SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal anatomy.

METHODS

From March 2013 to November 2013, s-SBE-assisted ERCP was done in our hospital in 26 postoperative patients who had surgically altered anatomy. We retrospectively evaluated the success rate of reaching the blind end, the mean time required to reach the blind end, the diagnostic success rate, the therapeutic success rate, the mean procedure time, and complications.

RESULTS

The success rate of reaching the blind end was 92.3%. The mean time required to reach the blind end was 25.3 min. The diagnostic success rate was 91.7%. The diagnostic success rate for naïve papilla was 75%. The mean procedure time was 56.0 min. The success rate of overall s-SBE-assisted ERCP was 84.6%. The complication rate was 3.8%.

CONCLUSION

Diagnostic and therapeutic ERCP using a newly developed s-SBE is sufficiently effective.

Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection

BACKGROUND AND AIM

In patients with Roux-en-Y hepaticojejunostomy (HJ with R-Y) and Whipple resection, endoscopic retrograde cholangiopancreatography (ERCP) can be challenging. We report our experience with ERCP using balloon-assisted enteroscopy (BAE) (BAE-ERCP) in patients with HJ with R-Y, and Whipple resection.

METHODS

BAE-ERCP procedures were carried out in 62 patients (HJ with R-Y:Whipple resection=34:28).

RESULTS

Overall, the rates of reaching the anastomosis were 85.3% (29/34) in HJ with R-Y and 96.4% (27/28) in Whipple resection. In terms of HJ with R-Y, insertion success rate by standard single-balloon enteroscopy (SBE) was 89.3% (25/28). Insertion success rate by short BAE, including SBE and double-balloon enteroscopy (DBE), was 50% (3/6). There was a statistically significant difference of insertion success rate between standard long BE and short BE (P=0.021). However, in the Whipple patients, insertion success rate by standard and short SBE was 93.8% (15/16) and 91.7% (11/12), respectively. Initial insertion success rate by short BAE in Whipple patients was significantly higher than in HJ with R-Y (91.7% vs 50%, P=0.045). Therapeutic interventions included dilation of anastomosis stricture, stone extraction, endoscopic mechanical lithotripsy, biliary stent placement, stent extraction, endoscopic nasobiliary drainage, direct cholangioscopy, and electrohydraulic lithotripsy. Our HJ with R-Y series and Whipple series treatment success rate was 90% (18/20) and 95.0% (19/20), respectively.

CONCLUSIONS

BAE-ERCP enabled ERCP to be carried out in patients with HJ. It is considered safe and feasible. Further experience and device improvement are needed.

Short double-balloon enteroscopy is feasible and effective for endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) for patients with digestive tract reconstruction is a difficult procedure from an anatomical point of view. A short-type double-balloon enteroscope has a 2.8-mm working channel and a 152-cm working length, and its advantage is that it can accommodate most conventional devices for ERCP. Although the shorter length compared with the long-type balloon-assisted enteroscope (BAE) was suspected of making it difficult or impossible to reach the blind end, in fact, the success rate of reaching the blind end with the short type is similar to that with the long- type BAE. In addition, the success rate of ERCP-related procedures with the short type is satisfactory. However, it remains controversial as to which BAE is more suitable for this procedure. Further randomized controlled trials by high-volume centers are warranted.

Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy

Endoscopic treatment for pancreatobiliary diseases is less invasive than surgery and percutaneous transhepatic biliary drainage is highly beneficial to patients. The endoscopic approach is indicated for an increasing number of patients, including those who have undergone previous gastrointestinal surgery, although these patients face two major challenges. First, the endoscopic approach to the afferent loop, blind end, and the site of choledochojejunostomy is difficult with the use of a conventional endoscope because of the distance from the gastrojejunal anastomosis site, unusual anatomical features of the intestine such as its winding shape, and postoperative adhesion. Second, it is difficult to reach Vater's papilla or the site of choledochojejunostomy and to cannulate selectively into the pancreatic and/or biliary duct. The balloon-assisted endoscope (BAE), a recently developed technology, can be useful for carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. ERCP using the BAE is highly effective and safe in patients with altered gastrointestinal anatomy, especially in patients with Roux-en-Y reconstruction.

Intrahepatic cholangiocarcinoma diagnosed via endoscopic retrograde cholangiopancreatography with a short double-balloon enteroscope

Endoscopic retrograde cholangiopancreatography (ERCP) using a double-balloon enteroscope (DBE) in patients with bowel reconstruction due to a previous abdominal surgery is now widely accepted. In particular, a short DBE, which has a 2.8-mm working channel and 152-cm working length, is useful for ERCP because of its good rotational and straightening ability and the availability of various conventional ERCP accessories through the working channel. Herein we report a case of intrahepatic cholangiocarcinoma via ERCP with a short DBE. This is the first report in which the pre-cutting and the brush cytological examination were performed successfully under a DBE to diagnose intrahepatic cholangiocarcinoma pathologically. The short DBE allowed us to perform all diagnostic and therapeutic procedures accepted in conventional ERCP in patients with surgically altered anatomies.

Recent advances in endoscopic management of difficult bile duct stones

Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.

A laparoscopic transgastric approach to the treatment of sphincter of Oddi dysfunction postgastric bypass

Obesity is endemic and bariatric surgery is increasing in an attempt to reduce the physiological and social cost. As the prevalence of bariatric surgery increases, in particular laparoscopic roux-en-Y gastric bypass (LRYGB), the need to investigate and treat subsequent pathology in the gastric remnant and biliary tree will accrue. We describe a novel combined surgical and endoscopic technique addressing the challenges of postoperative anatomy, allowing investigation and treatment of the gastric remnant and biliary tract. We present the case of a patient with sphincter of Oddi dysfunction post-LRYGB who underwent laparoscopic transgastric endoscopic injection of Botox into the ampulla with an excellent symptomatic relief. Subsequent laparoscopic transgastric sphincterotomy allowed definitive treatment and allowed symptom resolution at 6 months follow-up. Laparoscopic transgastric endoscopic investigation and treatment is a novel approach to circumvent the restrictions of post-LRYGB anatomy and may assume greater importance in an ageing obese population.

The concept of laparoscopy-assisted pancreatobiliary EUS (LAP-EUS)

INTRODUCTION

While laparoscopy-assisted endoscopic retrograde cholangiopancreatography can be performed for the diagnosis and management of pancreaticobiliary diseases in patients with Roux-en-Y (RY) anatomy; the technical feasibility of performing laparoscopy-assisted endoscopic ultrasound (EUS) is unknown.

METHODS

In this report, we describe the technique for performing laparoscopy-assisted EUS in two patients with RY gastric bypass anatomy who presented with obstructive jaundice, abnormal liver function tests, and dilated biliary tree.

RESULTS

While the examination was normal in one patient, EUS-guided fine needle aspiration of pancreatic head mass revealed adenocarcinoma in the other.

DISCUSSION

Laparoscopic assisted EUS examination including FNA is feasible in Roux-en-Y surgical anatomy.

Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy

AIM

To evaluate the effectiveness of a short-type single-balloon-enteroscope (SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a reconstructed intestine.

METHODS

Short-type SBE was developed to perform ERCP in postoperative patients with a reconstructed intestine. Short-type SBE is a direct-viewing endoscope with the following specifications: working length, 1520 mm; total length, 1840 mm; channel diameter, 3.2 mm. In addition, short-type SBE has a water-jet channel. The study group comprised 22 patients who underwent 31 sessions of short-type SBE-assisted ERCP from June 2011 through May 2012. Reconstruction was performed by Billroth-II (B-II) gastrectomy in 6 patients (8 sessions), Roux-en-Y (R-Y) gastrectomy in 14 patients (21 sessions), and R-Y hepaticojejunostomy in 2 patients (2 sessions). We retrospectively studied the rate of reaching the blind end (papilla of Vater or choledochojejunal anastomosis), mean time required to reach the blind end, diagnostic success rate (defined as the rate of successfully imaging the bile and pancreatic ducts), therapeutic success rate (defined as the rate of successfully completing endoscopic treatment), mean procedure time, and complications.

RESULTS

Among the 31 sessions of ERCP, the rate of reaching the blind end was 88% in B-II gastrectomy, 91% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The mean time required to reach the papilla was 18.3 min in B-II gastrectomy, 21.1 min in R-Y gastrectomy, and 32.5 min in R-Y hepaticojejunostomy. The diagnostic success rates in all patients and those with an intact papilla were respectively 86% and 86% in B-II gastrectomy, 90% and 87% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The therapeutic success rates in all patients and those with an intact papilla were respectively 100% and 100% in B-II gastrectomy, 94% and 92% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. Because the channel diameter was 3.2 mm, stone extraction could be performed with a wire-guided basket in 12 sessions, and wire-guided intraductal ultrasonography could be performed in 8 sessions. As for complications, hyperamylasemia (defined as a rise in serum amylase levels to more than 3 times the upper limit of normal) occurred in 1 patient (7 sessions) with a B-II gastrectomy and 4 patients (19 sessions) with an R-Y gastrectomy. After ERCP in patients with an R-Y gastrectomy, 2 patients (19 sessions) had pancreatitis, 1 patient (21 sessions) had gastrointestinal perforation, and 1 patient (19 sessions) had papillary bleeding. Pancreatitis and bleeding were both mild. Gastrointestinal perforation improved after conservative treatment.

CONCLUSION

Short-type SBE is effective for ERCP in patients with a reconstructed intestine and allows most conventional ERCP devices to be used.

Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications

Enteroscopy, defined as direct visualization of the small bowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past several years. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies one of which is non-invasive, the video capsule, and a type of invasive technique, the device-assisted enteroscopy. In particular, the device-assisted enteroscopy consists then of three different types of instruments all able to allow, in skilled hands, to display partially or throughout its extension (if necessary) the small intestine. Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocarcinoma or gastrointestinal stromal tumors. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

Utility of the Anterior Oblique-Viewing Endoscope and the Double-Balloon Enteroscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II Gastrectomy

Background/Purpose. The difficulties of endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy have been reported. We evaluated the usefulness of an anterior oblique-viewing endoscope and a double-balloon enteroscope for endoscopic retrograde cholangiopancreatography in such patients. Methods. From January 2003 to December 2011, 65 patients with Billroth II gastrectomy were enrolled in this study. An anterior oblique-viewing endoscope was used for all patients. From February 2007, a double-balloon enteroscope was used for the failed cases. The success rate of procedures was compared with those in 20 patients with Billroth II gastrectomy using forward-viewing endoscope or side-viewing endoscope from March 1996 to July 2002 as historical controls. Results. In all patients in whom the papilla was reached (60/65), selective cannulation was achieved. The success rate of selective cannulation and accomplishment of planned procedures in the anterior oblique-viewing endoscope group were both significantly higher than that in the control group (100% versus 70.1%, 100 versus 58.8%, resp.). A double-balloon enteroscope was used in 2 patients, and the papilla could be reached and the planned procedures completed. Conclusions. An anterior oblique-viewing endoscope and double-balloon enteroscope appear to be useful in performing endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy.

Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. However, it may lead to diseases of the bilio-pancreatic tract. We evaluated transgastric endoscopic retrograde cholangiopancreatography (ERCP) for managing common biliary tract diseases in patients that underwent RYGB treatment for obesity. This prospective study was conducted between 2003 and 2010 at three medical institutions. We included 23 patients with a mean body mass index of 28.2 kg/m(2) after RYGB treatment. ERCP was performed in all patients to manage biliary tract diseases within 9 to 27 months (mean 16.3 months) of RYGB surgery. The gastrotomy was conducted through the anterior wall of the greater curve of the excluded stomach. A duodenoscope was introduced in the direction of the ostomy to perform the ERCP with sphincterotomy. All patients underwent an ERCP and papillotomy without incident. Ten patients underwent simultaneous cholecystectomy. A total of 17 gallstones were removed. The average gastrotomy duration was 92.69 min; the average hospital stay was 2 days. One patient had mild acute pancreatitis that resolved clinically. There was no mortality. Laparoscopy-assisted transgastric ERCP was feasible and safe for patients after RYGB. The necessary equipment is available in most bariatric surgery centers.

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.

Altered anatomy: enteroscopy and ERCP procedure

Roux-en-Y entero-enteric anastomosis of the small bowel is a commonly used surgical technique. However, it excludes the afferent limb and the biliopancreatic system from conventional endoscopic access. Recent data have shown that device-assisted enteroscopy (DAE) allows endoscopic retrograde cholangiopancreatography (ERCP) in these patients with high success rates. Both Double-balloon, short Double-balloon, Single-balloon and Spiral enteroscopy can be used for DAE-ERCP with comparable success. This review highlights the currently available literature data on DAE-ERCP in patients with Roux-en-Y anastomosis, and discusses the clinical aspects and technical difficulties. Although DAE does increase ERCP efficacy in patients with Roux-en-Y anastomosis, it remains a challenging procedure which is open to further improvement.

Small bowel enteroscopy

Over the past decade, the advent of capsule endoscopy and balloon-assisted enteroscopy has revolutionized the approach to small intestinal diseases. The small bowel is no longer out of reach, and has fallen within the diagnostic and therapeutic realm of the gastrointestinal endoscopist. Double-balloon enteroscopy was the first type of balloon-assisted endoscopy and is the method for which there are the most data. Single-balloon enteroscopy has since been introduced as an alternative balloon-assisted method, followed more recently by the development of spiral overtube-assisted enteroscopy. The purpose of the present article is to review these methods of small bowel enteroscopy and to discuss the latest developments. While the investigation of small bowel diseases cannot be addressed without considering the central role of capsule endoscopy, a detailed assessment is beyond the scope of the present article, and capsule endoscopy will only be discussed as it pertains to enteroscopy.

Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy

INTRODUCTION

Roux-en-Y gastric bypass is increasingly performed in the United States. In addition, liver transplantation and other complex hepatobiliary surgeries are increasingly performed with creation of a Roux-en-Y hepaticojejunostomy. Consequently, endoscopists more frequently need to carry out endoscopic procedures in patients with Roux-en-Y anatomy.

MATERIALS AND METHODS

The present article discusses the techniques and instruments available to therapeutic endoscopists who are faced with the challenge of performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with long- or short-limb Roux-en-Y anatomy.

CONCLUSION

Endoscopists can successfully perform ERCP in patients with Roux-en-Y anatomy by making use of appropriate techniques and instruments.

Accessing the pancreatobiliary limb and ERCP in the bariatric patient

The Roux-en-Y gastric bypass (RYGB) accounts for more than 60% of bariatric procedures performed in the United States today. The RYGB anatomy poses particular challenges to interventional endoscopists who intend to access the papilla. Deep enteroscopy-assisted endoscopic retrograde cholangiopancreatography seems to be the least invasive technique for this purpose, and is often the best initial choice. However, considerable experience is needed to optimize the success rate of reaching the biliopancreatic limb, with subsequent successful cannulation, and which approach is taken should be determined on a case-by-case basis.

Large balloon dilatation following endoscopic sphincterotomy using a balloon enteroscope for the bile duct stone extractions in patients with Roux-en-Y anastomosis

BACKGROUND

Extraction of bile duct stones in patients who have undergone Roux-en-Y anastomosis can be challenging. Recently, large balloon dilation following endoscopic sphincterotomy has been shown to be useful for the removal of bile duct stones.

AIM

We retrospectively evaluated the feasibility and safety of endoscopic sphincterotomy large balloon dilation for the removal of bile duct stones in patients with Roux-en-Y anastomosis.

METHODS

Large balloon papillary dilation following EST for the removal of bile duct stones was performed on the intact papilla in 15 patients with Roux-en-Y anastomosis at our institution. When we could not use the long-type accessories, a conventional forward-viewing upper endoscope passed through the over tube of the single-balloon or double-balloon enteroscope for the use of short-type accessories. Following endoscopic sphincterotomy, a large balloon catheter was positioned across the main duodenal papilla. The size of large balloon used ranged from 15mm to 20mm.

RESULTS

Complete clearance of bile duct stones was achieved in all cases in the initial session without any adverse events. A mechanical lithotriptor for crushing stones was used in one patient (6.7%).

CONCLUSION

Large balloon papillary dilation following EST appears to be an effective and safe treatment for difficult-to-remove bile duct stones in patients with Roux-en-Y anastomosis .

Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis

Background

There have been a few previous reports on attempted double-balloon endoscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis and an intact papilla. This study was designed to evaluate the usefulness of DBE-assisted ERCP in patients with Roux-en-Y anastomosis and an intact papilla of Vater.

Methods

Thirteen DBE procedures were performed in nine patients who had undergone Roux-en-Y reconstruction combined with eight total gastrectomies and one partial gastrectomy. Both short-type and long-type DBE were used. Long-type DBE was replaced with a conventional forward-viewing upper endoscope after reaching the papilla. Technical success rate, measurement of procedure times, and adverse events were evaluated in the retrospective study.

Results

In all cases, the scopes could reach the papilla. The mean time required to reach the papilla was 48 (range, 13–90) min. There was a statistically significant difference with the short and long scope (29.0 ± 19.2 min vs. 64.8 ± 24.7 min, respectively; P = 0.044). The success rate of bile duct cannulation, resulting in achieving therapeutic ERCP on the first session was 66.7% (6/9). The mean procedural time in the successful cases was 128 (range, 47–183) min. Finally, therapeutic ERCP was achieved in all nine cases. There was one adverse event in which retroperitoneal perforation during lithotripsy, but that was successfully treated by conservative therapy alone.

Conclusion

DBE-assisted ERCP seems to be a promising option to perform therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis.

Ultrathin endoscope-assisted ERCP for inaccessible peridiverticular papilla by a single-balloon enteroscope in a patient with Roux-en-Y anastomosis

We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux-en Y (R-Y). A 73-year-old man who had total gastrectomy with R-Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre-cutting, the ultraslim endoscope was replaced with a conventional forward-viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure-related complication.

Direct cholangioscopy using a double-balloon enteroscope: choledochojejunostomy with intraductal biliary carcinoma

A 75-year-old man who underwent choledochojejunostomy for gallstones 30 years ago was hospitalized for general malaise. Abdominal computed tomography revealed marked dilation of the intrahepatic bile duct in the right lobe and an image of a hypervascular tumor. Endoscopic retrograde cholangiography using double-balloon enteroscopy (DBE) showed a filling defect that was localized to the right hepatic bile duct. Furthermore, the scope was able to readily pass through the anastomosed site of the choledochojejunostomy and, therefore, we observed the interior of the bile duct using the same scope. We obtained an image showing a whitish, papillary-like tumor, and a biopsy of the tumor rendered the pathology of intraductal papillary mucinous carcinoma. Direct cholangioscopy using DBE is a useful diagnostic tool, particularly in patients with a past history of choledochojejunostomy.

Laparoscopy-assisted transjejunal ERCP in a patient with Roux-en-Y reconstruction following partial gastrectomy

In this article, we report a patient with a history of partial gastrectomy and Roux-en-Y reconstruction who presented with abdominal pain due to sphincter of Oddi dysfunction. After failed endoscopic retrograde cholangiopancreatography (ERCP) through the anatomic route, the procedure was successfully performed with laparoscopy assistance through an enterotomy into the biliopancreatic limb. An internal hernia was diagnosed incidentally and treated appropriately. Laparoscopy-assisted ERCP is a viable option in patients with Roux-en-Y anatomy, even when the gastric remnant and duodenum are not available.

Experiences of biliary interventions using short double-balloon enteroscopy in patients with Roux-en-Y anastomosis or hepaticojejunostomy

BACKGROUND

The efficacy of double-balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux-en-Y gastrectomy or hepaticojejunostomy (HJ).

PATIENTS AND METHODS

Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux-en-Y reconstruction or HJ anastomosis.

RESULTS

A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively.

CONCLUSIONS

Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.

Large dilating balloon to allow endoscope insertion for successful endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy (with video)

BACKGROUND AND PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy can be present unique challenges. One of the major obstacles preventing successful ERCP is acute angulation and long afferent loops in patients with Billroth II gastrectomy or Roux-en-Y anastomosis. Here, we described a novel technique for successful endoscope insertion using a large dilating balloon.

METHODS

The large dilating balloon (maximum diameter 20 mm) is used as an anchor for endoscope insertion (hooking method) in patients with Billroth II gastrectomy in whom no other endoscopes could be advanced into the end of the duodenum or the Roux-en-Y anastomosis.

RESULTS

The hooking method allows the endoscope to be advanced into the proximal afferent loop, even in patients with sharp angulation of the Y limb.

CONCLUSIONS

To the best of our knowledge, this is the first report on the use of a large dilating balloon for endoscope insertion in patients with surgically altered anatomy, in particular Roux-en-Y anastomosis. We believe this technique may be effective for difficult cases like the present case.

Advances in endoscopic retrograde cholangiopancreatography cannulation

Endoscopic retrograde cholangiopancreatography is an important tool in the diagnosis and treatment of pancreatobiliary diseases. A critical step in this procedure is deep cannulation of the bile duct as failure of cannulation generally results in an aborted procedure and failed intervention. Expert endoscopists usually achieve a high rate of successful cannulation while those less experienced typically have a much lower rate and a greater incidence of complications. Prolonged attempts at cannulation can result in significant morbidity to patients, anxiety for endoscopists, unnecessary radiation exposure and inefficient patient care. Here we review the most common endoscopic techniques used to achieve selective biliary cannulation. Pharmacologic aids to cannulation are also discussed briefly in this review.

Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy

Bariatric surgery has been increasingly performed in response to the obesity pandemic. During the last decade, Roux-en-Y gastric bypass (RYGB) has become the preferred surgical approach. It is also commonly performed after pylorus preserving pancreaticoduodenectomy and other biliary tract surgeries. This article discusses the different options available for endoscopists who are faced with the need to perform endoscopic retrograde cholangiopancreatography in patients after Roux-en-Y reconstruction, with special emphasis on those after RYGB.

Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy

BACKGROUND

In patients with surgically altered anatomy, ERCP is often unsuccessful. Single-balloon enteroscopy (SBE) enables deep intubation of the small bowel, permitting diagnostic and therapeutic ERCP in this subset of patients.

OBJECTIVE

To determine the effectiveness of SBE in performing endoscopic retrograde cholangiography (ERC) in patients with surgically altered anatomy.

DESIGN

Case series.

SETTING

Large quaternary-care center.

PATIENTS

Thirteen patients (11 women) underwent 16 SBE procedures with ERCP. Patient anatomy consisted of Whipple (n = 3), hepaticojejunostomy (n = 3), Billroth II (n = 1), and Roux-en-Y (n = 9).

INTERVENTIONS

Patients with surgically altered anatomy in whom standard ERCP techniques had failed or were not possible underwent ERC by using SBE with initial therapeutic intent.

MAIN OUTCOME MEASUREMENTS

Success rates of diagnostic ERC and therapeutic ERC in those patients who required biliary intervention. Procedure-related complications were also assessed.

RESULTS

Diagnostic ERC was successful 12 (92.3%) of 13 patients and in 13 (81.3%) of 16 cases. Therapeutic ERC was required in 10 patients in whom diagnostic ERC was first accomplished, and therapeutic ERC was successful in 9 (90%) of 10 patients. Biliary interventions included balloon dilation (n = 4), stone extraction (n = 2), sphincterotomy (n = 4), removal of a surgically placed stent (n = 3), and stenting (n = 2). Two patients developed pancreatitis after therapeutic ERC. Median follow-up was 53 days (range 22-522 days). Overall procedural success in an intent-to-treat analysis by case was 75%.

LIMITATION

Single-center experience.

CONCLUSION

SBE enables diagnostic and therapeutic ERC in most patients with altered anatomy. SBE-assisted therapeutic ERC may be associated with an increased risk of pancreatitis. Improvement of the available equipment is necessary to perform more efficient and effective biliary interventions.

Single Balloon Enteroscopy-Assisted ERCP Using Rendezvous Technique for Sharp Angulation of Roux-en-Y Limb in a Patient with Bile Duct Stones

The acute angulation of Roux-en-Y (R-Y) limb precludes endoscopic access for endoscopic retrograde cholangiopancreatography (ERCP) even using a balloon enteroscopy. Here, we describe a case of successful single balloon enteroscopy (SBE)-assisted ERCP using a rendezvous technique in a patient with sharply angulated R-Y limb in a 79-year-old woman who had bile duct stones. Method. At first, a guidewire was passed antegradely through the major papilla after the needle puncture using percutaneous transhepatic biliary drainage technique. A hydrophilic guidewire with an ERCP catheter was antegradely advanced beyond the Roux limb. After a guidewire was firmly grasped by a snare forceps, it was pulled out of the body, resulting that the enteroscope could advance to the papilla. After papillary dilation, complete removal of bile duct stones was achieved without any procedure-related complication. In conclusion, although further study is needed, SBE-assisted ERCP using a rendezvous technique may have a potential for selected patients.

Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video)

OBJECTIVES

The aim of this study was to evaluate the usefulness of single-balloon enteroscopy (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy (B-II) or Roux-en-Y anastomosis (R-Y).

METHODS

Thirteen SBE procedures were performed in 2 patients with B-II and 11 patients with R-Y at Tokyo Medical University Hospital. SBE was replaced with a conventional forward-viewing upper endoscope after reaching the papilla. This is a retrospective cohort study.

RESULTS

In all cases but one (92.3%, 12/13), the papilla or anastomotic site could be reached with the SBE. The rate for B-II and R-Y were 100% (2/2) and 90.9% (10/11), respectively. The mean time required to reach the papilla or anastomotic site was 33.3 min (range, 5-86 min). In cases of R-Y, the mean time required to reach the papilla or anastomotic site was 35.5 min (range, 12-76 min). The overall success rate of the therapeutic ERCP on the first session was 76.9% (10/13). In patients with an intact papilla, the success rate on the first session was 72.3% (8/11). With regard to the type of surgery, the success rate of the procedure in patients with B-II and R-Y was 100% (2/2) and 72.3% (8/11), respectively. The mean procedural time for 10 successful groups on the first session was 66.4 min (range, 25-152 min). No adverse events occurred.

CONCLUSIONS

SBE-assisted ERCP using an overtube-assisted technique appears to be promising for performing therapeutic ERCP in patients with B-II or R-Y.

Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video)

BACKGROUND

Laparoscopy-assisted ERCP (LAERCP) allows the diagnosis and treatment of biliopancreatic conditions in patients with Roux-en-Y anatomy (RY). However, experience with this technique is limited.

OBJECTIVES

To report on the experience with LAERCP in consecutive patients from a high-volume bariatric surgery center and to evaluate success rates of ERCP with the laparoscopy-assisted approach.

DESIGN

Retrospective case series.

SETTING

High-volume bariatric surgery center.

PATIENTS

Consecutive patients undergoing LAERCP between 2003 and 2009.

INTERVENTION

LAERCP.

OUTCOMES

Immediate/delayed complications, biliary/pancreatic duct cannulation, endoscopic/laparoscopic interventions, postprocedure hospital stay, procedure duration.

RESULTS

Ten patients underwent LAERCP: 9 after Roux-en-Y gastric bypass (RYGB) and 1 after antrectomy with RY (9 female, 1 male; 9 white, 1 black). Indications for the procedure were choledocholithiasis (n=4), biliary stricture (n=3), and sphincter of Oddi dysfunction (n=3). Endoscopic access was obtained to the gastric remnant (n=9) or biliopancreatic limb (n=1). Biliary cannulation was successfully achieved in 9 of 10 patients, biliary sphincterotomy was performed in all, pancreatography in 3 of 3, and sphincter of Oddi manometry in 2. In 1 patient, a 3F pancreatic duct stent was placed prophylactically. Mild post-ERCP pancreatitis developed in 2 patients, and 1 patient had a pneumothorax intraoperatively that was treated successfully. The mean duration of the procedure was 89 minutes (range 41-245), and the median postprocedure hospital stay was 2 days (mean 2.59, standard deviation 2.46).

LIMITATIONS

Single-center, retrospective design.

CONCLUSION

LAERCP is safe and successful for the diagnosis and therapy of biliopancreatic conditions in patients with RY. It additionally allows the diagnosis and treatment of internal hernias, a known complication of RYGB.