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Chon HK, Kozarek RA. History of the Interventional Pancreaticobiliary Endoscopy. Gastrointest Endosc Clin N Am 2024; 34:383-403. [PMID: 38796288 DOI: 10.1016/j.giec.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
With the introduction of endoscopic retrograde cholangiopancreatography and linear endoscopic ultrasound, interventional pancreaticobiliary (PB) endoscopy has had an enormous impact in the management of pancreatic and biliary diseases. Continuous efforts to improve various devices and techniques have revolutionized these treatment modalities as viable alternatives to surgery. In recent years, trends toward combining endoscopic techniques with other modalities, such as laparoscopic and radiological interventions, for complex PB diseases have emerged using a multidisciplinary approach. Ongoing research and clinical experience will lead to refinements in interventional PB endoscopic techniques and subsequently improve outcomes and reduce complication rates.
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Affiliation(s)
- Hyung Ku Chon
- Division of Biliopancreas, Department of Internal Medicine, Wonkwang University Medical School, and Hospital, Iksan, Republic of Korea; Institution of Wonkwang Medical Science, Iksan, Republic of Korea
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1100 Ninth Avenue, Seattle, WA 98101, USA; Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Avenue, Seattle, WA 98101, USA.
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2
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Fasullo M, Patel M, Khanna L, Shah T. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000778. [PMID: 35552193 PMCID: PMC9109012 DOI: 10.1136/bmjgast-2021-000778] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 12/29/2022] Open
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.
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Affiliation(s)
- Matthew Fasullo
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Milan Patel
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Lauren Khanna
- Gastroenterology, New York University Medical Center, New York, New York, USA
| | - Tilak Shah
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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3
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Fasullo M, Shah T, Zhou H, Siddiqui MS. Post-Transplant Biliary Strictures: An Updated Review. Semin Liver Dis 2022; 42:225-232. [PMID: 35263796 DOI: 10.1055/s-0042-1744144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease with excellent long-term survival; however, LT recipients are at risk of significant complications. Among these complications are biliary complications with an incidence ranging from 5 to 32% and associated with significant post-LT morbidity and mortality. Prompt recognition and management are critical as these complications have been associated with mortality rates up to 19% and retransplantation rates up to 13%. An important limitation of published studies is that a large proportion does not discriminate between anastomotic strictures and nonanastomotic strictures. This review aims to summarize our current understanding of risk factors and natural history, diagnostic testing, and treatment options for post-LT biliary strictures.
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Affiliation(s)
- Matthew Fasullo
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Tilak Shah
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Huiping Zhou
- Department of Microbiology and Immunology, VCU and McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mohammad S Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia
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da Ponte-Neto AM, Bernardo WM, de A Coutinho LM, Josino IR, Brunaldi VO, Moura DTH, Sakai P, Kuga R, de Moura EGH. Comparison between Enteroscopy-Based and Laparoscopy-Assisted ERCP for Accessing the Biliary Tree in Patients with Roux-en-Y Gastric Bypass: Systematic Review and Meta-analysis. Obes Surg 2019; 28:4064-4076. [PMID: 30288669 DOI: 10.1007/s11695-018-3507-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although balloon-assisted enteroscopy-endoscopic retrograde cholangiopancreatography (BAE-ERCP) is a well-described means of accessing the duodenal papilla in patients with Roux-en-Y gastric bypass (RYGB), it is associated with modest clinical success rates. Laparoscopy-assisted ERCP (LA-ERCP)-performed by advancing a standard duodenoscope through a gastrostomy into the excluded stomach and duodenum-has emerged as a viable alternative to BAE-ERCP, with apparently higher success rates. In this systematic review, we compare LA-ERCP with enteroscopy-based techniques in post-RYGB patients, including 22 case series that provided data on papilla identification, papilla cannulation, and complications. We found that LA-ERCP was superior to the enteroscopy-based techniques in its capacity to reach the duodenal papilla, although complication rates were lower for the latter. Comparative studies are needed in order to corroborate our findings.
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Affiliation(s)
- Alberto Machado da Ponte-Neto
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil. .,, São Paulo, Brazil.
| | - Wanderley M Bernardo
- Thoracic Surgery Department, Instituto do Coração (InCor, Heart Institute), University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Lara M de A Coutinho
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil
| | - Iatagan Rocha Josino
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil
| | - Diogo T H Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil
| | - Rogério Kuga
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil
| | - Eduardo G H de Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar, 155, 6 andar, São Paulo, SP CEP 05403-900, Brazil
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Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography: Preliminary experience and technique description. J Visc Surg 2019; 156:381-386. [PMID: 30885707 DOI: 10.1016/j.jviscsurg.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Ang TL. When the balloon goes up …. J Gastroenterol Hepatol 2019; 34:483-484. [PMID: 30821413 DOI: 10.1111/jgh.14633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Chang JH, Lee I, Choi MG, Han SW. Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation. World J Gastroenterol 2016; 22:1593-1606. [PMID: 26819525 PMCID: PMC4721991 DOI: 10.3748/wjg.v22.i4.1593] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/02/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
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Soh JS, Yang DH, Lee SS, Lee S, Bae J, Byeon JS, Myung SJ, Yang SK. Single Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients Who Underwent a Gastrectomy with Roux-en-Y Anastomosis: Six Cases from a Single Center. Clin Endosc 2015; 48:452-7. [PMID: 26473133 PMCID: PMC4604288 DOI: 10.5946/ce.2015.48.5.452] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/22/2014] [Accepted: 12/16/2014] [Indexed: 12/29/2022] Open
Abstract
Patients with altered anatomy such as a Roux-en-Y anastomosis often present with various pancreaticobiliary problems requiring therapeutic intervention. However, a conventional endoscopic approach to the papilla is very difficult owing to the long afferent limb and acute angle of a Roux-en-Y anastomosis. Balloon-assisted enteroscopy can be used for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered anatomy. We experienced six cases of Roux-en-Y anastomosis with biliary problems, and attempted ERCP using single balloon enteroscopy (SBE). SBE insertion followed by replacement with a conventional endoscope was attempted in five of six patients. The papilla was successfully approached using SBE in all cases. However, therapeutic intervention was completed in only three cases because of poor maneuverability caused by postoperative adhesion. We conclude that in patients with Roux-en-Y anastomosis, the ampulla can be readily accessed with SBE, but longer dedicated accessories are necessary to improve this therapeutic intervention.
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Affiliation(s)
- Jae Seung Soh
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seohyun Lee
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jungho Bae
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Shimatani M, Takaoka M, Tokuhara M, Miyoshi H, Ikeura T, Okazaki K. Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy. World J Gastrointest Endosc 2015; 7:617-627. [PMID: 26078830 PMCID: PMC4461936 DOI: 10.4253/wjge.v7.i6.617] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 01/14/2015] [Accepted: 03/09/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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Skinner M, Velázquez-Aviña J, Mönkemüller K. Using balloon-overtube-assisted enteroscopy for postoperative endoscopic retrograde cholangiopancreatography. Therap Adv Gastroenterol 2014; 7:269-79. [PMID: 25364385 PMCID: PMC4212471 DOI: 10.1177/1756283x14544154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is technically more challenging in patients with postsurgical anatomy such as Roux-en-Y anastomosis, frequently mandating an operative intervention. Although limited, there is growing evidence that ERCP can be performed using the balloon-overtube-assisted enteroscopy (BOAE) in patients with complex postoperative anatomy. We present the technical aspects of performing ERCP with the BOAE in patients presenting with complex postsurgical anatomy having biliary problems. ERCP using the BOAE is feasible in patients with complex postsurgical anatomy, permitting diagnostic and therapeutic interventions in 80% of patients.
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Affiliation(s)
- Matthew Skinner
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, AL, USA
| | - Jacobo Velázquez-Aviña
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, AL, USA
| | - Klaus Mönkemüller
- Division of Gastroenterology and Hepatology, Basil Hirschowitz Endoscopic Center of Excellence, Endoscopy Unit, JT 664, 619 19th Street S, Birmingham, AL 35249, USA
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Li K, Huang YH, Yao W, Chang H, Huang XB, Zhang YP, Song ZQ. Adult colonoscopy or single-balloon enteroscopy-assisted ERCP in long-limb surgical bypass patients. Clin Res Hepatol Gastroenterol 2014; 38:513-9. [PMID: 24560303 DOI: 10.1016/j.clinre.2014.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/08/2013] [Accepted: 01/03/2014] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the usefulness of adult colonoscopy or single-balloon enteroscopy (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in long-limb surgical bypass patients. METHODS Retrospective analysis of 16 patients with long-limb surgical bypasses who underwent therapeutic ERCP because of suspected pancreaticobiliary diseases. Small-bowel intubation was performed by peroral adult colonoscopy or SBE. If colonoscopy success was achieved, ERCP was performed subsequently. But in patients using SBE, a small-caliber colonoscope would be used to replace enteroscope if the SBE success was achieved. ERCP was then performed with the conventional accessories. RESULTS A total of 21 ERCP procedures were performed. Adult colonoscope was used for ERCP in 8 patients with standard Whipple resection consecutively. Colonoscopy success was achieved in 8 of 8 patients (100%), of whom 7 of 8 (87.5%) achieved ERCP success. SBE-assisted ERCP was attempted in other 8 patients with different types of Roux-en-Y anatomy. SBE success was achieved in 7 of 8 patients (87.5%), of whom 4 of 7 (57.1%) achieved ERCP success. The overall success rate of endoscopy and ERCP was 93.8% (15/16) and 68.8% (11/16), respectively. CONCLUSIONS Adult colonoscopy has high success rate for performing ERCP after Whipple resection and should be selected for such patient preferentially. By using the facilitated method for endoscopic interventions at pancreaticobiliary disease after Roux-en-Y reconstruction, SBE-assisted ERCP can be attempted when it is difficult to gain access to the papilla of Vater or bilioenteric/pancreaticoenteric anastomosis and long length ERCP accessories cannot be available.
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Affiliation(s)
- Ke Li
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Road, Haidian District, 100191 Beijing, China
| | - Yong-Hui Huang
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Road, Haidian District, 100191 Beijing, China.
| | - Wei Yao
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Road, Haidian District, 100191 Beijing, China
| | - Hong Chang
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Road, Haidian District, 100191 Beijing, China
| | - Xue-Biao Huang
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Road, Haidian District, 100191 Beijing, China
| | - Yao-Peng Zhang
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Road, Haidian District, 100191 Beijing, China
| | - Zhi-Qiang Song
- Department of Gastroenterology, Peking University Third Hospital, 49 North Garden Road, Haidian District, 100191 Beijing, China
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Shimatani M, Takaoka M, Ikeura T, Mitsuyama T, Okazaki K. Evaluation of endoscopic retrograde cholangiopancreatography using a newly developed short-type single-balloon endoscope in patients with altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 2:147-55. [PMID: 24750166 DOI: 10.1111/den.12283] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 02/13/2014] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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Tomizawa Y, Sullivan CT, Gelrud A. Single balloon enteroscopy (SBE) assisted therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with roux-en-y anastomosis. Dig Dis Sci 2014; 59:465-70. [PMID: 24185681 DOI: 10.1007/s10620-013-2916-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/05/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis is a complex challenge. Long length of afferent limb after an acute angle at the jejunojejunostomy and altered location of the biliary orifice make biliary cannulation difficult. Single balloon enteroscopy assisted ERCP (SBE-ERCP) is a promising alternative to conventional approaches. AIM The purpose of this study was to assess the efficacy and safety of SBE-ERCP in patients with Roux-en-Y reconstruction at a high volume tertiary referral center. METHODS This is a retrospective cohort study. All procedures were performed by a single, experienced pancreatobiliary endoscopist. Patient demographics and related clinical data were obtained. The rate of procedure successes and complications were determined. RESULTS Fourteen patients (nine women) with a median age of 63 years (range 35-83 years) underwent 22 SBE-ERCP procedures from March 2009 to May 2011. Surgically altered anatomy consisted of Whipple procedure (n = 4), hepaticojejunostomy (n = 9) and partial gastrectomy (n = 1). Indications for SBE-ERCP were obstructive jaundice (n = 10), cholangitis (n = 7), post-PTC internalization (n = 3) and biliary stent extraction/exchange (n = 2). The hepaticojejunostomy site (HJS) was reached in 15 (68 %) procedures. Successful interventions were performed in 11 (73 %) of 15 cases, including balloon dilation of biliary strictures (n = 3), insertion of biliary stents (n = 7), retrieval of biliopancreatic stents (n = 4) and biliary stone extraction (n = 4). The mean procedural time for successful interventions was 97.6 min (range 73-147 min). No procedural complications occurred during the median follow-up of 501 days (range 22-1,242 days). CONCLUSION SBE-ERCP is safe and carries an acceptable success rate in experienced hands.
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Affiliation(s)
- Yutaka Tomizawa
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Shimatani M, Takaoka M, Matsushita M, Okazaki K. Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 1:70-8. [PMID: 24118126 DOI: 10.1111/den.12175] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/16/2013] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
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Kianička B, Lata J, Novotný I, Dítě P, Vaníček J. Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejunoanastomosis. World J Gastroenterol 2013; 19:8047-8055. [PMID: 24307799 PMCID: PMC3848153 DOI: 10.3748/wjg.v19.i44.8047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 08/22/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepaticojejunoanastomosis (HJA).
METHODS: The study took place from January 2009 to December 2011 and we retrospectively assessed 15 patients with Roux-en-Y HJA who had signs of biliary obstruction. In total, 23 ERC procedures were performed in these patients and a single balloon videoenteroscope (Olympus SIF Q 180) was used in all of the cases. A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope. Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of ≤ 5.4 kPa. The technical limitations or rather the parameters of the single balloon enteroscope (working length - 200 cm, diameter of the working channel - 2.8 mm, absence of Albarran bridge) showed the need for special endoscopic instrumentation.
RESULTS: Cannulation success was reached in diagnostic ERC in 12 of 15 patients. ERC findings were normal in 1 of 12 patients. ERC in the remaining 11 patients showed some pathological changes. One of these (cystic bile duct dilation) was subsequently resolved surgically. Endoscopic treatment was initialized in the remaining 10 patients (5 with HJA stenosis, 2 with choledocholithiasis, and 3 with both). This treatment was successful in 9 of 10 patients. The endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis - 11 times (7 patients); choledocholitiasis extraction - five times (5 patients); biliary plastic stent placement - six times (4 patients); and removal of biliary stents placed by us - six times (4 patients). The mean time of performing a single ERC was 72 min. The longest procedure took 110 min and the shortest took 34 min. This shows that it is necessary to allow for more time in individual procedures. Furthermore, these procedures require the presence of an anesthesiologist. We did not observe any complications in these 15 patients.
CONCLUSION: This method is more demanding than standard endoscopic retrograde cholangiopancreatography due to altered postsurgical anatomy. However, it is effective, safe, and widens the possibilities of resolving biliary pathology.
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Abstract
Within the last decade, the technological development improved the diagnostic work-up of small bowel diseases. In addition to abdominal ultrasound and radiological methods, the importance of endoscopy is increasing. Nowadays, five nonsurgical flexible endoscopy techniques are available for small bowel endoscopy: push enteroscopy and balloon-guided enteroscopy for evaluation of the proximal small bowel, balloon-assisted enteroscopy using two balloons (double-balloon enteroscopy) or one balloon (single-balloon enteroscopy), and spiral enteroscopy for evaluation of the deep small bowel. Intraoperative enteroscopy has become a reserve method.
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Affiliation(s)
- Andrea May
- Department of Internal Medicine II, HSK Wiesbaden, Wiesbaden, Germany.
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Prospective study of therapeutic spiral enteroscopy in patients with surgically altered anatomy. Surg Endosc 2012; 27:671-8. [DOI: 10.1007/s00464-012-2485-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 06/19/2012] [Indexed: 12/19/2022]
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Wagh MS, Draganov PV. Prospective evaluation of spiral overtube-assisted ERCP in patients with surgically altered anatomy. Gastrointest Endosc 2012; 76:439-43. [PMID: 22817798 DOI: 10.1016/j.gie.2012.04.444] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 04/06/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Mihir S Wagh
- Division of Gastroenterology, University of Florida, Gainesville, Florida 32610, USA
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Altered anatomy: enteroscopy and ERCP procedure. Best Pract Res Clin Gastroenterol 2012; 26:347-57. [PMID: 22704576 DOI: 10.1016/j.bpg.2012.03.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 03/05/2012] [Accepted: 03/06/2012] [Indexed: 01/31/2023]
Abstract
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.
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Spiral assisted ERCP is equivalent to single balloon assisted ERCP in patients with Roux-en-Y anatomy. Dig Dis Sci 2012; 57:1391-8. [PMID: 22198702 DOI: 10.1007/s10620-011-2000-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 11/22/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is often unsuccessful in patients with Roux-en-Y anatomy. Augmented enteroscopy allows deep insertion into the small bowel and can be useful in patients with Roux-en-Y anatomy. The aim of this study was to compare single balloon assisted ERCP (SBE-ERCP) and spiral assisted ERCP (SE-ERCP) in patients with Roux-en-Y anatomy in terms of diagnostic and therapeutic yield, procedure time, and complications. METHODS This is a retrospective cohort study of consecutive patients with Roux-en-Y anatomy who underwent SBE-ERCP or SE-ERCP between October 2007 and March 2011. Diagnostic yield was defined as successful duct cannulation. Therapeutic yield was defined as the ability to successfully carry out endoscopic therapy in those cannulated. Procedure time and complications were assessed. RESULTS Thirty-four consecutive patients with Roux-en-Y anatomy underwent 54 ERCP procedures. The overall diagnostic yield was 44.4% with no significant difference between the diagnostic yield of SBE-ERCP (48.3%) and SE-ERCP (40%). The diagnostic yield was lower in patients with gastric by-pass (38.9%) compared with other types of Roux-en-Y anatomy (47.2%) but this was not statistically significant (P = 0.772). The overall therapeutic yield was 93.8%, with a therapeutic yield of 100% for SBE-ERCP and 87.5% for SE-ERCP (P = 1.0). There was one perforation during SBE-ERCP, giving a complication rate of 3.5%. The mean procedure time did not differ between the two techniques. CONCLUSION Diagnostic and therapeutic yields are similar with SBE-ERCP and SE-ERCP in patients with Roux-en-Y anatomy with no significant difference in procedure time or complication rates.
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Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:332-8. [PMID: 21140174 DOI: 10.1007/s00534-010-0361-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Abstract
Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.
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Affiliation(s)
- Choong Heon Ryu
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.
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Affiliation(s)
- Choong Heon Ryu
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Matsushita M, Shimatani M, Ikeura T, Takaoka M, Okazaki K. Single-balloon or short double-balloon enteroscope for ERCP in patients with surgically altered anatomies. Gastrointest Endosc 2011; 73:415-6; author reply 416-7. [PMID: 21295661 DOI: 10.1016/j.gie.2010.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 06/14/2010] [Indexed: 12/11/2022]
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Abstract
Nowadays, 5 nonsurgical flexible endoscopic techniques are available for small bowel endoscopy: push enteroscopy (PE), balloon-assisted enteroscopy using 2 balloons (double-balloon enteroscopy [DBE]) or 1 balloon (single-balloon enteroscopy [SBE]), balloon-guided enteroscopy (BGE), and spiral enteroscopy (SE). PE is a cost-saving, easy, and fast procedure for the examination of the proximal jejunum, but for a deep small bowel endoscopy, the other flexible enteroscopic techniques are required. BGE does not play a considerable role in deep small bowel endoscopy. DBE is the oldest flexible enteroscopic technique. Actually, the balloon-assisted enteroscopy (BAE) techniques with one balloon (SBE) or two balloons (DBE) are the mainly used techniques. DBE has become established throughout the world for diagnostic and therapeutic examinations of the small bowel and is now used universally in clinical routine work. DBE is still regarded as the gold standard nonsurgical procedure for deep small bowel endoscopy, because it provides the highest rates of complete enteroscopy, which becomes increasingly useful. The recently introduced SE technique represents a promising method but still needs technical improvement. Larger prospective studies on SE and prospective studies comparing the 3 systems (DBE, SBE, SE) are awaited before conclusive assessments can be made.
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Affiliation(s)
- Andrea May
- Department of Internal Medicine II, HSK Wiesbaden, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany.
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Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis. Surg Endosc 2010; 25:713-21. [PMID: 20976503 PMCID: PMC3044838 DOI: 10.1007/s00464-010-1226-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 11/12/2009] [Indexed: 02/06/2023]
Abstract
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.
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Itoi T, Ishii K, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Tsuji S, Ikeuchi N, Moriyasu F, Sakai Y. Ultrathin endoscope-assisted ERCP for inaccessible peridiverticular papilla by a single-balloon enteroscope in a patient with Roux-en-Y anastomosis. Dig Endosc 2010; 22:334-6. [PMID: 21175491 DOI: 10.1111/j.1443-1661.2010.01028.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Layec S, D'Halluin PN, Pagenault M, Sulpice L, Meunier B, Bretagne JF. Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: a new role for double-balloon enteroscopy. Gastrointest Endosc 2010; 72:449-51. [PMID: 20541191 DOI: 10.1016/j.gie.2010.03.1063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 03/08/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic interventions are usually very challenging in patients with anatomic changes caused by earlier GI surgery. The recent development of the double-balloon enteroscopy (DBE) system creates an opportunity to reach the biliary tract and the pancreatic duct in postsurgical conditions. OBJECTIVE To report a further application of DBE in surgical patients; namely, extraction of pancreatic stents placed in pancreaticojejunal anastomosis during pancreaticoduodenectomy. DESIGN Two case reports. SETTING A single-center experience in a tertiary-care unit. PATIENTS AND INTERVENTIONS Two patients who underwent Whipple resection with Roux-en-Y reconstruction presented with migration of pancreatic stent tubes inserted in pancreaticojejunal anastomoses. Stents had migrated to the end of the afferent limb and were causing abdominal pain. Because extraction failed by using conventional endoscopy, we used the DBE system. MAIN OUTCOME MEASURES Successful extraction of the stents. RESULTS Stents were successfully removed in both patients with no complications. After 1 year of follow-up, the patients remained free of painful symptoms. LIMITATIONS Small volume case series. CONCLUSIONS Double-balloon enteroscopy is a reliable way to investigate and treat patients with postsurgical altered anatomy. Here, we report the successful removal of pancreatic stents migrating into the jejunal loop through pancreaticojejunal anastomosis.
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Affiliation(s)
- Sabrina Layec
- Service des maladies de l'appareil digestif, Centre hospitalo-universitaire, Rennes, France
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Single balloon enteroscopy for endoscopic retrograde cholangiography in a patient with hepaticojejunostomy after liver transplant. Gastroenterol Res Pract 2010; 2010:701696. [PMID: 20454574 PMCID: PMC2864447 DOI: 10.1155/2010/701696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 02/05/2010] [Accepted: 03/02/2010] [Indexed: 01/28/2023] Open
Abstract
We report a case of a post-transplant patient with hepaticojejunostomy in whom we used a single balloon enteroscopy to access the biliary tree. This procedure seems to be safe and feasible for approaching the biliary anastomosis by means of the overtube and fixation of the small bowel by the balloon.
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30
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Qayed E, Reid AL, Willingham FF, Keilin S, Cai Q. Advances in endoscopic retrograde cholangiopancreatography cannulation. World J Gastrointest Endosc 2010; 2:130-7. [PMID: 21160728 PMCID: PMC2998904 DOI: 10.4253/wjge.v2.i4.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 04/01/2010] [Accepted: 04/08/2010] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Emad Qayed
- Emad Qayed, Ashley L Reid, Field F Willingham, Steve Keilin, Qiang Cai, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
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Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010; 105:575-81. [PMID: 20051942 DOI: 10.1038/ajg.2009.712] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Double-balloon enteroscopy (DBE) is now an established method for diagnostic and therapeutic small-bowel endoscopy. Single-balloon enteroscopy (SBE) has been introduced to simplify the technique. A prospective randomized study was carried out to compare the two methods. METHODS The study included 100 patients (50 in each group; 63 men, 37 women; mean age 55 years), with no previous small-bowel or colon surgery. The indications for enteroscopy were (suspected) mid-gastrointestinal bleeding, Crohn's disease, small-bowel masses, chronic diarrhea or abdominal pain or both, and other conditions. Fujinon instruments were used, with either two balloons or one. The end point of the study was complete enteroscopy as the most objective parameter. RESULTS No severe complications such as perforation, bleeding, or pancreatitis occurred. Instrument preparation time was significantly faster with SBE than with DBE (P<0.0001). Complete enteroscopy was achieved with the DBE technique in 66% of cases (33 patients), either with the oral route alone or with combined oral and anal approaches. With the SBE technique, the complete enteroscopy rate was significantly lower at 22% (P<0.0001; 11 patients, only with oral and anal routes combined). The rate of therapeutic consequences for the patients based on diagnostic yield and negative complete enteroscopy was significantly higher (P=0.025) in the DBE group at 72%, compared with 48% in the SBE group. CONCLUSIONS The complete enteroscopy rate was three times higher with DBE than with SBE, accompanied by a higher diagnostic yield. DBE must therefore continue to be regarded as the nonsurgical gold standard procedure for deep small-bowel endoscopy.
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Lopes TL, Wilcox CM. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Gastroenterol Clin North Am 2010; 39:99-107. [PMID: 20202583 DOI: 10.1016/j.gtc.2009.12.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Tercio L Lopes
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Wang AY, Sauer BG, Behm BW, Ramanath M, Cox DG, Ellen KL, Shami VM, Kahaleh M. Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy. Gastrointest Endosc 2010; 71:641-9. [PMID: 20189529 DOI: 10.1016/j.gie.2009.10.051] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 10/30/2009] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia 22908, USA
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Matsushita M, Shimatani M, Takaoka M, Okazaki K. Effective endoscope for endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis: a single-, double-, or "short" double-balloon enteroscope? Dig Dis Sci 2010; 55:874-5; author reply 875. [PMID: 20108120 DOI: 10.1007/s10620-009-1110-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Single Balloon Enteroscopy-Assisted ERCP Using Rendezvous Technique for Sharp Angulation of Roux-en-Y Limb in a Patient with Bile Duct Stones. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2010; 2009:154084. [PMID: 20169091 PMCID: PMC2821765 DOI: 10.1155/2009/154084] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 12/21/2009] [Indexed: 01/08/2023]
Abstract
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.
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Itoi T, Ishii K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, Tsuji S, Ikeuchi N, Umeda J, Moriyasu F. Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video). Am J Gastroenterol 2010; 105:93-9. [PMID: 19809409 DOI: 10.1038/ajg.2009.559] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan.
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Lopes TL, Clements RH, Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc 2009; 70:1254-9. [PMID: 19846085 DOI: 10.1016/j.gie.2009.07.035] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 07/22/2009] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Tercio L Lopes
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama 35294-0007, USA
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Abstract
Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Non-anastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.
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Dellon ES, Kohn GP, Morgan DR, Grimm IS. Endoscopic retrograde cholangiopancreatography with single-balloon enteroscopy is feasible in patients with a prior Roux-en-Y anastomosis. Dig Dis Sci 2009; 54:1798-803. [PMID: 18989776 DOI: 10.1007/s10620-008-0538-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 09/11/2008] [Indexed: 12/11/2022]
Abstract
The purpose of this study is to describe the feasibility of using single-balloon enteroscopy (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who had a prior Roux-en-Y (RY) anastomosis. This case series describes four patients, one with RY gastric bypass, two with RY due to bile duct injury, and one with RY after liver transplantation, who underwent ERCP with SBE. Cholangiography was successful in three of the four patients. In the procedure that was not successful, the enteroenterostomy site could not be located. The successful procedures ranged from 65-91 min in duration. Medication doses were higher than with typical ERCPs. No procedural complications occurred. SBE for ERCP is a feasible option for endoscopic access to the biliary tree in patients with prior RY anastomoses. Limitations of this technique include the time requirement, delay in identification of the enteroenterostomy site, potential learning curve, and immature technology lacking accessories.
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Affiliation(s)
- Evan S Dellon
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, 130 Mason Farm Rd., Chapel Hill, NC 27599-7080, USA.
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Abstract
Double-balloon endoscopy (DBE) was developed based on the principle of preventing stretching of the intestinal tract by anchoring the convoluted intestinal tract with an endoscope and overtube fitted with inflatable balloons. The DBE system includes the main body of the endoscope with a built-in air channel, a balloon attached to the tip of the endoscope, an overtube with a hydrophilic coating equipped with an inflatable balloon, and a balloon controller that safely inflates/deflates the two balloons. At present, there are three different types of endoscopes for DBE. The indications for DBE include the diagnosis or treatment of various small intestinal conditions such as obscure gastrointestinal bleeding, Crohn's disease, and benign and malignant tumors. In addition, DBE can be used to approach the surgically modified intestinal tract; conventional endoscopes have difficulty in that situation. DBE can be used for colonoscopy in cases in which it is difficult to insert a conventional colonoscope. In the future, DBE will have the potential for wider use in routine colonoscopy because the insertion technique is easy and reliable.
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Affiliation(s)
- Keijiro Sunada
- Department of Endoscopic Research and International Education, Jichi Medical University, Shimotsuke, Tochigi 329-0498, Japan
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Ross AS. Endoscopic retrograde cholangiopancreatography in the surgically modified gastrointestinal tract. Gastrointest Endosc Clin N Am 2009; 19:497-507. [PMID: 19647654 DOI: 10.1016/j.giec.2009.04.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in the patient with altered intestinal anatomy secondary to surgery presents significant challenges to the endoscopist. Navigating anastamoses, cannulation using a forward viewing endoscope in a retrograde position and use of specialized instruments encompass just a few of the unique issues which arise when attempting ERCP in patients with surgically altered anatomy. This article focuses on instruments, technique and a review of the published literature to date on performing ERCP in this group of patients.
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Affiliation(s)
- Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA 98101, USA.
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Abstract
Balloon enteroscopy is a method that allows endoscopic inspection of the entire small bowel, or large parts of it, while simultaneously making it possible to obtain histologic samples and carry out treatment measures. Studies of double-balloon enteroscopy (DBE) have confirmed the high diagnostic yield of the procedure, with an acceptably low complication rate (approximately 1% for diagnostic DBE and 3% to 4% for therapeutic DBE). The principal indication for the procedure is midgastrointestinal bleeding, that is, when the bleeding source is located in the small bowel. With good patient selection, the diagnostic yield here is 70% to 80%, and this has a substantial influence on subsequent treatment measures. Single-balloon enteroscopy appears to be a simplification of the technique that is easier to handle, but few original studies have been published on the topic to date, and the results of prospective and controlled studies with larger numbers of patients must therefore be awaited. At present, DBE must still be regarded as the standard method for diagnostic and therapeutic endoscopy in the small bowel, avoiding the need for intraoperative enteroscopy or therapeutic laparotomy.
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Affiliation(s)
- Andrea May
- Department of Internal Medicine II, HSK Wiesbaden, Teaching Hospital-Johannes Gutenberg University, 65199 Wiesbaden, Germany.
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Abstract
Single-balloon enteroscopy has emerged as a viable alternative to double-balloon enteroscopy in the management of small bowel disease. Technically, it is easier to perform, may be more efficient, and in the limited literature available, seems to provide similar diagnostic and therapeutic yield when compared with double-balloon enteroscopy. This review provides up-to-date views on this emerging technology and its application.
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Kuga R, Safatle-Ribeiro AV, Sakai P. Utility of Double Balloon Endoscopy for the Diagnosis and Treatment of Stomach and Small Intestine Disorders in Patients with Gastric Bypass. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2008. [DOI: 10.1016/j.tgie.2008.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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