ERCP for altered Roux-en-Y anatomy: a single-balloon or short double-balloon enteroscope?

We read with interest the article by Saleem et al. [1] on the use of single-balloon enteroscopy (SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in 50 patients (56 procedures) with altered Roux-en-Y anatomy. After failed ERCP with a conventional colonoscope in 22 procedures, ERCP with SBE was successful in 15 / 22 (68 %) procedures. Overall diagnostic and therapeutic successes were achieved in 39 / 56 (70 %) and 21 / 23 (91 %) procedures, respectively. Because a single-balloon enteroscope has a 200-cm working length, they used a limited selection of long accessories, and called for development of longer-length accessories. We believe that the use of short double-balloon enteroscopy (s-DBE) would solve the problem.

ERCP is technically challenging, and often unsuccessful in patients with Roux-en-Y surgical reconstruction because of the inability to reach the anastomosis [2] [3] [4] [5]. When the papilla or the choledochoenterostomy site is reached, it is difficult to carry out selective cannulation and therapeutic procedures. With the recent advent of balloon-assisted enteroscopy, DBE and SBE can visualize a much longer segment of the small bowel than does standard endoscopy, and can be applied to ERCP in such patients [2] [3] [4] [5]. Several investigators have performed ERCP with DBE or SBE in patients with Roux-en-Y anastomosis, resulting in high rates of diagnostic and therapeutic success [3] [4] [5]. Because these enteroscopes have 200-cm working lengths, the use of specialized custom-made accessories or of a very limited selection of available long accessories was required [2] [3] [4] [5].

We have first reported a case series of ERCP for surgically altered anatomy in which we used an s-DBE device (EC450-BI5; Fujinon, Tokyo, Japan) with a 2.8-mm working channel and a 152-cm working length, for which all conventional accessories are available [2]. Recently, we have reported in this journal a large case series of 103 ERCPs in which we used s-DBE; this involved 68 patients, with Roux-en-Y total gastrectomy (n = 36), Billroth II gastrectomy (n = 17), and pancreatoduodenectomy (n = 15) [5]. Deep insertion (100 / 103), cholangiography (98 / 100), and therapeutic interventions (98 / 98) were highly successful. The therapeutic interventions performed successfully included stone extraction (n = 47), nasobiliary drainage (n = 38), plastic or metallic stent placement (n = 36), sphincterotomy (n = 31), choledochojejunostomy dilation (n = 29), tumor biopsy (n = 10), and nasopancreatic duct drainage (n = 1).

As all conventional accessories are available, we therefore recommend the s-DBE for ERCP in patients who have undergone bowel reconstruction such as Roux-en-Y anastomosis

References

• 1 Saleem A, Baron T H, Gostout C J et al. Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy.  Endoscopy. 2010;  42 656-660
• 2 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
• 3 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
• 4 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
• 5 Shimatani M, Matsushita M, Takaoka M et al. Effective ”short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series.  Endoscopy. 2009;  41 849-854