Endoscopic ultrasound-guided pancreaticobiliary intervention in patients with surgically altered anatomy and inaccessible papillae: A review of current literature

Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred modality for drainage of the obstructed biliary tree. In patients with surgically altered anatomy, ERCP using standard techniques may not be feasible. Enteroscope assisted ERCP is usually employed with variable success rate. With advent of endoscopic ultrasound (EUS), biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective. In this narrative review, we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Laparoscopic assisted ERCP in patient with Roux-en-Y gastric bypass. A case report

INTRODUCTION

Choledocholithiasis in Roux-en-Y patients is a therapeutic challenge for both surgeons and endoscopists. In fact, typical procedures, such as ERCP, can't be performed due to the altered anatomy of the patient. Nowadays, procedures on this kind of patient are performed not only in specialized bariatric centers, but, due to the increasing number of patients undergoing bariatric surgery, are starting to become more common even in smaller and non-specialized centers that don't possess the same expertise and technology.

CASE PRESENTATION

We present the case of a 33-year-old patient, who had already undergone bariatric surgery, and presented to our department with a diagnosis of choledocholithiasis. Due to the altered anatomy the patient was treated through a laparoscopic assisted ERCP.

DISCUSSION

A review of the need and proper timing for a cholecystectomy in this kind of patient, in order to prevent choledocholithiasis, is discussed. Moreover, a review of the literature regarding the possible treatments of this pathology in bariatric patients underlines the presence of other treatments, beyond the one performed in our department, that can be performed even in small non-specialized centers.

CONCLUSIONS

Prophylactic cholecystectomy is not recommended in bariatric surgery. Laparoscopic assisted-ERCP is a safe and feasible intervention which is to be preferred, even if B-ERCP and EDGE are two valid alternatives.

EUS-directed transgastric endoscopic retrograde cholangiopancreatography versus laparoscopic-assisted ERCP versus deep enteroscopy-assisted ERCP for patients with RYGB

Background and study aims  Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) is a novel technique for managing pancreaticobiliary diseases in patients with a history of Roux-en-Y Gastric Bypass (RYGB). It has shown to have high technical success rates and fewer adverse events as compared to laparoscopic-assisted ERCP (LA-ERCP). We compared the technical success and clinical outcomes of EDGE vs. LA-ERCP vs. E-ERCP. Patients and methods  A retrospective chart review was performed for 56 patients, of whom 18 underwent LA-ERCP, 12 underwent E-ERCP, and 26 had EDGE, and a comparison of technical success and complication rates was done. Results  Baseline demographic characteristics of patients undergoing these procedures, including age and gender, were comparable. The technical success rate for patients in the EDGE group were 100 % (n = 26), compared with 94 % (n = 17) and 75 % (n = 9) in the LA-ERCP and E-ERCP groups ( P  = 0.02). In the EDGE group, 8 % of patients (n = 2) had bleeding, and 4 % of patients (n = 1) had lumen-apposing metal stent migration occur during the procedure. In the LA-ERCP group 6 % (n = 1) of patient had bleeding, 6 % (n = 1) post-ERCP pancreatitis and 6 % (n = 1) were diagnosed with an intra-abdominal infection post-procedure. Time to complete the EDGE procedure was significantly shorter at 79 ± 31 mins, compared with 158 ± 50 mins for LA-ERCP and 102 ± 43 mins for E-ERCP ( P  < 0.001). Conclusion  EDGE is a novel procedure with short procedure times and an effective alternative to LA-ERCP and E-ERCP in management of pancreaticobiliary diseases in patients with a history of RYGB.

Treatment of Difficult Minor Papilla Cannulation in Patients of Pancreatic Divisum: Using Endoscopic Ultrasonography-guided Puncture Combined With Endoscopic Retrograde Cholangiopancreatography: 2 Cases and Literature Review

CONTEXT

Pancreas divisum (PD), the most common congenital anatomic variation of the pancreatic ductal system, is still rare in clinical practice. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for patients with symptomatic PD. However, even by experienced endoscopists, the procedure of ERCP can fail in 3% to 10% of cases. Traditionally, if we fail in cannulation we have no choice but to rely on surgery.

CASE REPORT

The 2 case reports of PD in this study with cannulation were both unsuccessful, fortunately, the use of endoscopic ultrasonography-guided pancreatic duct puncture combined with ERCP was eventually successful in treatment.

CONCLUSIONS

Using endoscopic ultrasonography-guided pancreatic duct puncture combined with ERCP is safe and effective for the treatment of the patients of difficult minor papilla cannulation in patients of PD, and can be used as a remedy for minor papilla cannulation failure.

Advanced Endoscopic Procedures: An Update for Radiologists

OBJECTIVE. The purposes of this article are to familiarize radiologists with endoscopic techniques currently in use and to improve identification of clinically relevant imaging findings and procedural complications related to common endoscopic interventions. CONCLUSION. The frequency of performance of therapeutic endoscopic ultrasound-guided procedures has risen precipitously in the last decade. These procedures are replacing surgical and percutaneous approaches to a variety of disease entities. Recent advances include endoscopic bariatric procedures, endoscopic myotomies, and endoscopic ultrasound-guided drainage procedures.

Catheter probe extraductal ultrasound (EDUS) exploration of the common bile duct is safe in elderly patients with suspicion of choledocholithiasis after distal gastrectomy

PURPOSE

Post-surgical upper gastrointestinal anatomy may hamper a complete bilio-pancreatic evaluation with a standard echoendoscope. The aim of this study was to assess the role of catheter probe extraductal ultrasound (EDUS) for the evaluation of the common bile duct (CBD) in patients who are status post-gastric surgery and who are suspected of having choledocholithiasis.

METHODS

We retrospectively analyzed patients with a prior history of gastric surgery, who underwent EDUS for a suspicion of CBD obstruction. For each patient, technical success, accuracy, and safety were recorded. In case of a positive finding of CBD stones, endoscopic retrograde cholangiopancreatography (ERCP) was performed. In case of other findings or a negative EDUS, computed tomography or magnetic resonance cholangiopancreatography (MRCP) was performed as appropriate.

RESULTS

EDUS was technically successful in all the 11 patients with a Billroth II gastrectomy, while it failed in all the 5 patients with Roux-en-Y gastric surgery. EDUS accuracy was 100% (3 true-positive and 8 true-negative cases). CBD stones, confirmed and successfully extracted at ERCP, were found in two patients, while in one patient EDUS showed a CBD stenosis that was treated with a plastic stent during ERCP; computed tomography at follow-up was negative for cancer. EDUS was correctly negative in 8 patients, as confirmed by MRCP.

CONCLUSIONS

EDUS may represent an accurate and safe alternative to standard endoscopic ultrasonography and MRCP for the detection of CBD stones in elderly patients who are status post-Billroth II gastric surgery.

Techniques for endoscopic retrograde cholangiopancreatography in altered gastrointestinal anatomy

PURPOSE OF REVIEW

This review highlights the current status of endoscopic retrograde cholangiopancreatography (ERCP) techniques in patients with altered anatomy. Endoscopic treatment of biliopancreatic disorders is particularly challenging in patients with altered anatomy.

RECENT FINDINGS

There are two main approaches to perform ERCP in patients with altered anatomy: the transluminal access and the transmural access. The transluminal access uses device-assisted enteroscopy (DAE) to reach and cannulate the biliopancreatic system. The transmural access is created using therapeutic endoscopic ultrasound (EUS) or surgery to reach the biliopancreatic system. Both techniques are under continuous development and optimization.

SUMMARY

Based on the currently available data in the literature, the transluminal access is the preferred first-line approach because of an acceptable success rate and an excellent safety profile, whereas the transmural approach may be more efficacious but with a higher complication rate, even in experienced hands. Due to the complexity of both techniques and the relative low number of procedures, patients with altered anatomy are best referred to high-volume centres where both techniques are available for optimal treatment.