Peroral direct cholangioscopy with an ultraslim gastroscope in combination with a short double-balloon enteroscope for reconstructed biliary anatomy

We read with interest the article by Itoi et al. [1] on ultraslim endoscope-assisted therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with a papilla that was inaccessible by double-balloon enteroscopy (DBE) in a patient with Roux-en-Y anastomosis. Although DBE could reach the papilla, selective cannulation failed because of the difficult location of the papilla. After creating an aperture in the overtube because of the shorter length of an ultraslim endoscope, they replaced the DBE device with an ultraslim endoscope, and were able to place a biliary stent and transpapillary nasocystic catheter. They also described this method for a peridiverticular papilla that was inaccessible by single-balloon enteroscopy (SBE) in a patient with Roux-en-Y anastomosis [2].

Despite their claim that this was the first report of an ultraslim endoscope-assisted therapeutic ERCP, we had already reported a more advanced technique in a patient with Roux-en-Y anastomosis [3] [4]. In 2009, we described successful endoscopic management of acute obstructive cholangitis by means of peroral direct cholangioscopy with an ultraslim gastroscope in combination with a short DBE instrument (EC450-BI5; Fujinon, Tokyo, Japan), which has a 2.8-mm working channel and a 152-cm working length, in a patient with Roux-en-Y biliary reconstruction [3] [4]. After hepaticojejunostomy balloon dilation with DBE, the DBE device was replaced with an ultraslim gastroscope, keeping the overtube in place, and lithotripsy was done under peroral direct cholangioscopy with the gastroscope.

ERCP is technically challenging, and often unsuccessful in patients with Roux-en-Y surgical reconstruction because of the inability to reach the anastomosis [1] [2] [3] [4] [5] [6]. 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 standard endoscopy, and can be used for ERCP in such patients [5] [6]. 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 [2] [5] [6]. 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 is required [2] [5] [6].

Although peroral “mother–baby” cholangioscopy appears safer and faster than a percutaneous approach, it remains expensive, time-consuming, and cumbersome, and requires two endoscopists [4]. Successful peroral direct cholangioscopy with an ultraslim gastroscope has been reported for biliary management in patients with normal gastrointestinal anatomy. The technique is less cumbersome, and offers real advantages, being done by a single endoscopist without the need of additional equipment or setup. With the assistance of a balloon catheter, guide wire, or overtube, the gastroscope can be advanced through the post-sphincterotomy papilla into the bile duct [4].

We have performed 284 ERCPs (in 171 patients) for surgically altered anatomy in which we have used a short DBE device with a high success rate because all conventional accessories were available [3] [4] [5] [6] [7]. In 53 of these ERCPs (in 31 patients with choledochojejunostomy), we used an ultraslim gastroscope in combination with a short DBE device for diagnostic and therapeutic biliary management; this involved Roux-en-Y biliary reconstruction (n = 15) and pancreatoduodenectomy (n = 16). After deep insertion (53/53) and choledochojejunostomy dilation with a short DBE device, the DBE device was replaced with an ultraslim gastroscope, with the overtube left in place, and biliary insertion with the gastroscope (50/53) was highly successful. Diagnostic and therapeutic interventions with the gastroscope included stone extraction (n = 31), nasobiliary drainage tube placement (n = 26), plastic stent placement (n = 11), and bile duct biopsy (n = 17). We therefore believe that our combination method would be effective for biliary management in patients with reconstructed biliary anatomy.

References

• 1 Itoi T, Ishii K, Sofuni A et al. Ultraslim endoscope-assisted therapeutic ERCP for inaccessible papilla by a double-balloon enteroscope in patients with Roux-en-Y anastomosis.  Endoscopy. 2011;  43 36-37
• 2 Itoi T, Ishii K, Sofuni A et al. Ultrathin endoscope-assisted ERCP for inaccessible peridiverticular papilla by a single-balloon enteroscope in a patient with Roux-en-Y anastomosis.  Dig Endosc. 2010;  22 334-336
• 3 Takaoka M, Shimatani M, Ikeura T et al. Diagnostic and therapeutic procedure with a short double-balloon enteroscope and cholangioscopy in a patient with acute cholangitis due to hepatolithiasis.  Gastrointest Endosc. 2009;  70 1277-1279
• 4 Matsushita M, Shimatani M, Ikeura T et al. Peroral direct cholangioscopy with an ultraslim gastroscope in combination with a short double-balloon enteroscope in patients with altered GI anatomy.  Gastrointest Endosc. 2010;  71 884
• 5 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
• 6 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
• 7 Matsushita M, Shimatani M, Takaoka M et al. Effective device for peroral direct cholangioscopy: double-balloon enteroscope or ultra-slim gastroscope?.  Endoscopy. 2009;  41 730