Download PDF
Endoscopy 2009; 41(10): 849-854
DOI: 10.1055/s-0029-1215108
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Effective ”short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series

M.  Shimatani1 , M.  Matsushita1 , M.  Takaoka1 , M.  Koyabu1 , T.  Ikeura1 , K.  Kato1 , T.  Fukui1 , K.  Uchida1 , K.  Okazaki1
  • 1Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
Further Information

Publication History

submitted 29 May 2009

accepted after revision 30 July 2009

Publication Date:
11 September 2009 (online)

Also available at
    Permissions and Reprints

See also:

Commentaire de travail de M. Shimatani et al., pp. 849Endoscopy 2009; 41(10): 921-921
DOI: 10.1055/s-0032-1306749

Background and study aims: Although endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal anatomy, a double-balloon enteroscope (DBE) permits examinations of a much longer segment of the small bowel than does a standard endoscope, and may be used to perform ERCP in such patients. Since only limited accessories are available for a conventional DBE, we performed ERCP with a ”short” DBE, which has a 2.8-mm working channel and a 152-cm working length and for which conventional accessories are available, in patients with altered gastrointestinal anatomy, and evaluated this alternative technique.

Patients and methods: In 68 patients with a Roux-en-Y total gastrectomy (n = 36), Billroth II gastrectomy (n = 17), or pancreatoduodenectomy (n = 15), ERCP (103 procedures) was performed with a ”short” DBE.

Results: Deep insertion was successful in 100/103 procedures (97 %). Cholangiogram was successfully obtained in 98/100 procedures (98 %). Treatment was accomplished in all 98 procedures in which a cholangiogram was obtained (100 %). Therapeutic interventions including stone extraction (n = 47), nasobiliary drainage (n = 38), stent placement (n = 36), sphincterotomy (n = 31), choledochojejunostomy dilation (n = 29), tumor biopsy (n = 10), and naso–pancreatic duct drainage (n = 1) were performed successfully. Complications occurred in 5/103 procedures (5 %), all in patients with Roux-en-Y reconstruction.

Conclusions: Despite the relatively high rate of complications seen in patients with Roux-en-Y reconstruction, ERCP with a ”short” DBE is effective in patients who have undergone bowel reconstruction.

References

  • 1 Elton E, Hanson B L, Qaseen T. et al . Diagnostic and therapeutic ERCP using an enteroscope and pediatric colonoscope in long-limb surgical bypass patients.  Gastrointest Endosc. 1998;  47 62-67
    CrossrefPubMedSearch in Google Scholar
  • 2 Gostout C J, Bender C E. Cholangiopancreatography, sphincterotomy, and common duct stone removal via Roux-en-Y limb enteroscopy.  Gastroenterology. 1988;  95 156-163
    PubMedSearch in Google Scholar
  • 3 Alberti-Flor J J, Hernandes M E, Ferrer J P. Endoscopic examination of common hepatic duct and cholangiography in a patient with previous Roux-en-Y hepaticojejunostomy and Billroth I operation.  Gastrointest Endosc. 1992;  38 636-638
    PubMedSearch in Google Scholar
  • 4 Hintze R E, Adler A, Veltzke W. et al . Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with Billroth II or Roux-en-Y gastrojejunostomy.  Endoscopy. 1997;  29 69-73
    Thieme ConnectPubMedSearch in Google Scholar
  • 5 Hintze R E, Adler A, Veltzke W. et al . Endoscopic sphincterotomy using S-shaped sphincterotome in patients with Billroth II or Roux-en-Y gastrojejunostomy.  Endoscopy. 1997;  29 74-78
    Thieme ConnectPubMedSearch in Google Scholar
  • 6 Wright B E, Cass O W, Freeman M L. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla.  Gastrointest Endosc. 2002;  56 225-232
    CrossrefPubMedSearch in Google Scholar
  • 7 Yamamoto H, Sekine Y, Sato Y. et al . Total enteroscopy with a nonsurgical steerable double-balloon method.  Gastrointest Endosc. 2001;  53 216-220
    Search in Google Scholar
  • 8 May A, Nachbar L, Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility, diagnostic and therapeutic yield in patients with suspected small bowel disease.  Gastrointest Endosc. 2005;  62 62-70
    CrossrefPubMedSearch in Google Scholar
  • 9 Forbes A, Cotton P B. ERCP and sphincterotomy after Billroth II gastrectomy.  Gut. 1984;  25 971-974
    CrossrefPubMedSearch in Google Scholar
  • 10 Rosseland A R, Osnes M, Kruse A. Endoscopic sphincterotomy (EST) in patients with Billroth II gastrectomy.  Endoscopy. 1981;  13 19-24
    Thieme ConnectPubMedSearch in Google Scholar
  • 11 Safrany L. Endoscopy and retrograde cholangiopancreatography after Billroth II operation.  Endoscopy. 1972;  4 98-202
    PubMedSearch in Google Scholar
  • 12 Osnes M, Rosseland A R, Aabakken L. Endoscopic retrograde cholangiography and endoscopic papillotomy in patients with a previous Billroth II resection.  Gut. 1986;  27 1193-1198
    CrossrefPubMedSearch in Google Scholar
  • 13 Lien F L, Chuan P S, Ka S H. et al . ERCP in post Billroth II gastrectomy patients: emphasis on technique.  Am J Gastroenterol. 1999;  94 144-148
    CrossrefPubMedSearch in Google Scholar
  • 14 Maaser C, Lenze F, Bokemeyer M. et al . Double balloon enteroscopy; a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system.  Am J Gastroenterol. 2008;  103 894-900
    CrossrefPubMedSearch in Google Scholar
  • 15 Aabakken L, Bretthauer M, Line P D. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis.  Endoscopy. 2007;  39 1068-1071
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Haber G B. Double balloon endoscopy for pancreatic and biliary access in altered anatomy (with videos).  Gastrointest Endosc. 2007;  66 S47-50
    CrossrefPubMedSearch in Google Scholar
  • 17 Mönkemüller K, Bellutti M, Neumann H. et al . Therapeutic ERCP with the double-balloon enteroscope in patients with Roux-en-Y anastomosis.  Gastrointest Endosc. 2008;  67 992-996
    CrossrefPubMedSearch in Google Scholar
  • 18 Chu Y C, Su S J, Yang C C. et al . ERCP plus papillotomy by use of double-balloon enteroscopy after Billroth II gastrectomy.  Gastrointest Endosc. 2007;  66 1234-1236
    CrossrefPubMedSearch in Google Scholar
  • 19 Emmett D S, Mallat D B. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series.  Gastrointest Endosc. 2007;  66 1038-1041
    CrossrefPubMedSearch in Google Scholar
  • 20 Koornstra J J, Fry L, Mönkemüller K. et al . ERCP with the balloon-assisted enteroscopy technique: a systematic review.  Dig Dis. 2008;  26 324-329
    CrossrefPubMedSearch in Google Scholar
  • 21 Shimatani M, Matsushita M, Takaoka M. et al . ”Short” double balloon enteroscope for endoscopic retrograde cholangiopancreatography with conventional sphincterotomy and metallic stent placement after Billroth II gastrectomy.  Endoscopy. 2009;  41 E19-20
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 Matsushita M, Shimatani M, Takaoka M. et al . ”Short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy.  Am J Gastroenterol. 2008;  103 3218-3219
    CrossrefPubMedSearch in Google Scholar
  • 23 Bagci S, Tuzun A, Ates Y. et al . Efficacy and safety of endoscopic retrograde cholangiopancreatography in patients with Billroth II anastomosis.  Hepatogastroenterology. 2005;  52 356-359
    PubMedSearch in Google Scholar
  • 24 Faylona J MV, Qadir A, Chan A CW. et al . Small-bowel perforation related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy.  Endoscopy. 1999;  31 546-549
    Thieme ConnectPubMedSearch in Google Scholar
  • 25 Kim M H, Lee S K, Lee M H. et al . Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope.  Endoscopy. 1997;  29 82-85
    Thieme ConnectPubMedSearch in Google Scholar
  • 26 Teplick S K, Flick P, Brandon J C. Transhepatic cholangiography in patients with suspected biliary disease and nondilated intrahepatic bile ducts.  Gastrointest Radiol. 1991;  16 193-197
    CrossrefPubMedSearch in Google Scholar
  • 27 Chahal P, Baron T H, Topazian M D. et al . Endoscopic retrograde cholangiopancreatography in post-Whipple patients.  Endoscopy. 2006;  38 1241-1245
    Thieme ConnectPubMedSearch in Google Scholar

M. ShimataniMD 

Third Department of Internal Medicine
Kansai Medical University

2-3-1 Shinmachi
Hirakata
Osaka 573-1191
Japan

Fax: +81-72-804-2061

Email: shimatam@hirakata.kmu.ac.jp