Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy

Background and study aims: Endoscopic retrograde cholangiopancreatography (ERCP) is challenging to perform in patients with postsurgical gastrointestinal anatomy. We assessed the diagnostic and therapeutic success rates using single-balloon enteroscopy in patients with Roux-en-Y anastomosis.

Patients and methods: Patients who underwent single-balloon ERCP between April 2008 and February 2010 were retrospectively identified using a computerized endoscopy database. Diagnostic success was defined as successful duct cannulation or securing the diagnosis, and therapeutic success was defined as the ability to successfully carry out endoscopic therapy. Complications of ERCP were defined according to standard criteria.

Results: A total of 50 patients (34-male, mean age 57 years, range 19 – 85 years) with Roux-en-Y anastomosis underwent ERCP using a single-balloon enteroscope on 56 occasions. Indications for ERCP were cholestasis, acute cholangitis, recurrent primary sclerosing cholangitis with strictures, and choledocholithiasis. Overall diagnostic success was achieved in 39 / 56 cases (70 %). Therapeutic success was achieved in 21/23 cases (91 %). In 16 cases therapeutic intervention was not required. Therapeutic interventions included balloon dilation of strictures (n = 14), retrieval of retained biliopancreatic stents (n = 5), biliary stone extraction (n = 2), insertion of biliopancreatic stents (n = 4), and biliary and pancreatic sphincterotomy (n = 5). No major complications occurred. Importantly, in 22 / 56 procedures (39 %) a prior attempt at ERCP failed using conventional colonoscopes; single-balloon ERCP was successful in 15 / 22 (68 %) of these cases.

Conclusions: Single-balloon ERCP is feasible in patients with complex postsurgical Roux-en-Y anastomosis, allows diagnostic evaluation and therapeutic intervention in patients with pancreaticobiliary disease, and is a useful salvage technique in the majority of patients in whom ERCP using colonoscopies has failed.

References

• 1 Suisse A, Yassin K, Lavy A. et al . Outcome and early complications of ERCP: a prospective single center study.  Hepatogastroenterology. 2005;  52 352-355
• 2 Aabakken L, Holthe B, Sandstad O. et al . Endoscopic pancreaticobiliary procedures in patients with a Billroth II resection: a 10-year follow-up study.  Ital J Gastroenterol Hepatol. 1998;  30 301-305
• 3 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
• 4 Chahal P, Baron T H, Topazian M D. et al . Endoscopic retrograde cholangiopancreatography in post-Whipple patients.  Endoscopy. 2006;  38 1241-1245
• 5 Farrell J, Carr-Locke D, Garrido T. et al . Endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy for benign and malignant disease: indications and technical outcomes.  Endoscopy. 2006;  38 1246-1249
• 6 Elton E, Hanson B L, Qaseem T. et al . Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients.  Gastrointest Endosc. 1998;  47 62-67
• 7 Yamamoto H, Kita H, Sunada K. et al . Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.  Clin Gastroenterol Hepatol. 2004;  2 1010-1016
• 8 Fry L C, Neumann H, Kuester D. et al . Small bowel polyps and tumours: endoscopic detection and treatment by double-balloon enteroscopy.  Aliment Pharmacol Ther. 2009;  29 135-42
• 9 Mönkemüller K, Weigt J, Treiber G. et al . Diagnostic and therapeutic impact of double-balloon enteroscopy.  Endoscopy. 2006;  38 67-72
• 10 Koornstra J J. Double balloon enteroscopy for endoscopic retrograde cholangiopancreaticography after Roux-en-Y reconstruction: case series and review of the literature.  Neth J Med. 2008;  66 275-279
• 11 Mönkemüller K, Fry L C, Bellutti M. et al . ERCP with the double balloon enteroscope in patients with Roux-en-Y anastomosis.  Surg Endosc. 2009;  23 1961-1967
• 12 Neumann H, Fry L C, Meyer F. et al . Endoscopic retrograde cholangiopancreatography using the single balloon enteroscope technique in patients with Roux-en-Y anastomosis.  Digestion. 2009;  80 52-57
• 13 Hartmann D, Eickhoff A, Tamm R. et al . Balloon-assisted enteroscopy using a single-balloon technique.  Endoscopy. 2007;  39 Suppl 1 E276
• 14 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
• 15 Dellon E S, Kohn G P, Morgan D R. et al . Endoscopic retrograde cholangiopancreatography with single-balloon enteroscopy is feasible in patients with a prior Roux-en-Y anastomosis.  Dig Dis Sci. 2009;  54 1798-1803
• 16 Matsushita M, Shimatani M, Takaoka M. et al . Double-balloon enteroscopy for ERCP in patients with altered GI anatomy: front-viewing, a drawback for biliary cannulation?.  Gastrointest Endosc. 2009;  70 601
• 17 Itoi T, Ishii K, Sofuni A. et al . Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video).  Am J Gastroenterol. 2010;  105 93-99
• 18 Wang A Y, Sauer B G, Behm B W. et al . Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy.  Gastrointest Endosc. 2010;  71 641-649