ERCP with the overtube-assisted enteroscopy technique: a systematic review

Background and study aim: Overtube-assisted enteroscopy (OAE) techniques have increased the ability to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass. The aim of this study was to compare the efficacy and safety of OAE-ERCP in patients with different configurations of upper gastrointestinal anatomy.

Patients and methods: A systematic review was performed following a literature search for papers published between 1966 and August 2013. The following databases were searched: MEDLINE (via PubMed), Embase, Cochrane library, and Scopus. The following end points were analyzed: diagnostic and therapeutic success rates, cannulation success rate, ERCP success rate, type of enteroscopy, types of intervention, complications.

Results: A total of 23 relevant reports on OAE procedures, including single-balloon, double-balloon, and spiral enteroscopy, were analyzed. Studies included a total of 945 procedures in 679 patients (age 2 – 91 years) who had a variety of postsurgical upper gastrointestinal anatomical configurations. Among patients who underwent Roux-en-Y with gastric bypass, endoscopic success was 80 % and ERCP success was 70 %. In patients who had undergone a Roux-en-Y with either a pancreaticoduodenectomy, pylorus-preserving pancreaticoduodenectomy, or hepaticojejunostomy, endoscopic success was 85 % and ERCP success was 76 %. In patients who had undergone a Billroth II procedure, endoscopic success was 96 % and ERCP success was 90 %. In patients with native papilla who underwent successful endoscopy, cannulation was successful in 90 % of patients compared with 92 % in patients with an anastomosis. Overall ERCP success for all attempts was approximately 74 %. Interventions included sphincterotomy, pre-cut papillotomy, anastomotic stricturoplasty, stone removal, stent insertion, stent replacement, and balloon dilation of stenotic anastomosis. There were 32 major complications among the 945 procedures (3.4 %).

Conclusion: Both endoscopic and ERCP success rates were highest in patients with Billroth II anatomy, followed by those with pancreaticoduodenectomy and Roux-en-Y hepaticojejunostomy; the lowest success rates were in patients with Roux-en-Y gastric bypass. Cannulation rates appeared to be equivalent in patients with both native papilla and biliary-enteric or pancreaticoenteric anastomoses. The diagnostic and therapeutic potential of balloon-assisted ERCP were high and the adverse event rate was low.

• References

• 1 Freeman ML, Guda NM. ERCP cannulation: a review of reported techniques. Gastrointest Endosc 2005; 61: 112-125
• 2 Chahal P, Baron TH, Topazian MD et al. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy 2006; 38: 1241-1245
• 3 Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53: 216-220
• 4 Haber GB. Double balloon endoscopy for pancreatic and biliary access in altered anatomy (with videos). Gastrointest Endosc 2007; 66 : 47-50
• 5 Neumann H, Fry LC, 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
• 6 Lennon AM, Kapoor S, Khashab M et al. Spiral assisted ERCP is equivalent to single balloon assisted ERCP in patients with Roux-en-Y anatomy. Dig Dis Sci 2012; 57: 1391-1398
• 7 Shah RJ, Smolkin M, Yen R et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013; 77: 593-600
• 8 Cho S, Kamalaporn P, Kandel G et al. ‘Short’ double-balloon enteroscope for endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract. Can J Gastroenterol 2011; 25: 615-619
• 9 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
• 10 Siddiqui AA, Chaaya A, Shelton C et al. Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study. Dig Dis Sci 2013; 58: 858-864
• 11 Osoegawa T, Motomura Y, Akahoshi K et al. Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2012; 18: 6843-6849
• 12 Choi EK, Chiorean MV, Coté GA et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013; 27: 2894-2899
• 13 Wang AY, Sauer BG, Behm BW et al. Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy. Gastrointest Endosc 2010; 71: 641-649
• 14 Saleem A, Baron TH, Gostout CJ et al. Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy. Endoscopy 2010; 42: 656-660
• 15 Schreiner MA, Chang L, Gluck M et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 2012; 75: 748-756
• 16 Raithel M, Dormann H, Naegel A et al. Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients. World J Gastroenterol 2011; 17: 2302-2314
• 17 Parlak E, Ciçek B, Dişibeyaz S et al. Endoscopic retrograde cholangiography by double balloon enteroscopy in patients with Roux-en-Y hepaticojejunostomy. Surg Endosc 2010; 24: 466-470
• 18 Aabakken L, Bretthauer M, Line PD. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy 2007; 39: 1068-1071
• 19 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
• 20 Pohl J, May A, Aschmoneit I et al. Double-balloon endoscopy for retrograde cholangiography in patients with choledochojejunostomy and Roux-en-Y reconstruction. Z Gastroenterol 2009; 47: 215-219
• 21 Mönkemüller K, Fry LC, Bellutti M et al. ERCP with the double balloon enteroscope in patients with Roux-en-Y anastomosis. Surg Endosc 2009; 23: 1961-1967
• 22 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
• 23 Azeem N, Tabibian JH, Baron TH et al. Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis. Gastrointest Endosc 2013; 77: 568-577
• 24 Emmett DS, Mallat DB. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series. Gastrointest Endosc 2007; 66: 1038-1041
• 25 Moreels TG, Hubens GJ, Ysebaert DK et al. Diagnostic and therapeutic double-balloon enteroscopy after small bowel Roux-en-Y reconstructive surgery. Digestion 2009; 80: 141-147
• 26 Chua TJ, Kaffes AJ. Balloon-assisted enteroscopy in patients with surgically altered anatomy: a liver transplant center experience (with video). Gastrointest Endosc 2012; 76: 887-891
• 27 Itoi T, Ishii K, Sofuni A et al. Large balloon dilation following endoscopic sphincterotomy using balloon enteroscope for the bile duct stone extractions in patients with Roux-en-Y anastomosis. Dig Liver Dis 2011; 43: 237-241
• 28 Nimura Y, Hayakawa N, Toyoda S et al. Percutaneous transhepatic cholangioscopy. Stomach Intestine 1981; 16: 681
• 29 Tsujino T, Yamada A, Isayama H et al. Experiences of biliary interventions using short double-balloon enteroscopy in patients with Roux-en-Y anastomosis or hepaticojejunostomy. Dig Endosc 2010; 22: 211-216
• 30 Matsushita M, Shimatani M, Ikeura T et al. ERCP for altered Roux-en-Y anatomy: a single-balloon or short double-balloon enteroscope?. Endoscopy 2011; 43: 169-173
• 31 Mönkemüller K, Jovanovic I. Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: a practical classification. World J Gastrointest Endosc 2011; 3: 213-219
• 32 Winick AB, Waybill PN, Venbrux AC. Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol 2001; 4: 200-206
• 33 Moreels TG. Altered anatomy: enteroscopy and ERCP procedure. Best Pract Res Clin Gastroenterol 2012; 26: 347-357
• 34 Lopes TL, Clements RH, Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc 2009; 70: 1254-1259
• 35 Williams EJ, Taylor S, Fairclough P et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007; 39: 793-801