ERCP using single-balloon instead of double-balloon enteroscopy in patients with Roux-en-Y anastomosis

A 60-year-old man underwent pancreatic necrosectomy and a Roux-en-Y anastomosis. Before surgery the patient had undergone an endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement, but this stent could not be removed intra-operatively. ERCP was carried out using the Fujinon double-balloon enteroscope (EN-450T5I, Fujinon, Saitama, Japan). For the ERCP we did not place a balloon on the tip of the enteroscope. Advancement of the enteroscope and overtube was accomplished using the push-and-pull method. Once the anastomosis was localized, the overtube was advanced towards the tip of the scope and the balloon was inflated. The enteroscope was then advanced into the afferent loop, and once it was 20 cm inside of the loop, the overtube balloon was deflated and advanced towards the tip of the scope. These push-and-pull maneuvers were repeated until the pouch of the afferent limb was visualized. The protruding stent helped localize the major papilla ([Fig. 1]). The stent was then grasped with a snare and retrieved ([Fig. 2]).

Fig. 1 After entering the blind pouch of the afferent limb a stent exiting the ampulla of Vater was visualized.

Fig. 2 The stent was then grasped with a snare and retrieved.

A 36-year-old man with chronic pancreatitis underwent a pylorus-preserving Whipple’s operation with Roux-en-Y hepaticojejunostomy. He presented because of cholestasis. ERCP was carried out using the single-balloon method described above. Sludge was found “glued” to the orifice of the hepaticojejunostomy ([Fig. 3]). The sludge was removed using a stone retrieval basket ([Fig. 4] and [5] ).

Fig. 3 Endoscopic view of the hepaticojejunostomy to which a large mass of sludge was found “glued”.

Fig. 4 The sludge and stones were removed using a stone retrieval basket.

Fig. 5 Note the large hepaticojejunostomy after it has been cleared from the sludge obstructing the bile outflow.

There are recent case reports on the feasibility of performing ERCP with the double-balloon enteroscopy in patients with Roux-en-Y anastomosis [1] [2]. Our cases suggest that ERCP using the single-balloon enteroscopy approach permits biliary interventions in patients with Roux-en-Y anastomosis. A potential advantage of using a single-balloon technique is time saving, as described for single-balloon colonoscopy [3]. In addition, occasionally the balloon of the scope slips over the tip, diminishing the endoscopic view and thus interfering with diagnostic and therapeutic interventions.

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References

• 1 Moreels T G, Roth B, Vandervliet E J. et al . The use of the double-balloon enteroscope for endoscopic retrograde cholangiopancreatography and biliary stent placement after Roux-en-Y hepaticojejunostomy.  Endoscopy. 2007;  DOI 10.1055/s-2007-966410
• 2 Chu Y C, Yeh Y H, Yang C C. et al . A new indication for double-balloon enteroscopy: removal of migrated metal stents through a Roux-en-Y anastomosis.  Endoscopy. 2007;  DOI 10.1055/s-2007-944921
• 3 May A, Nachbar L, Ell C. Push-and-pull enteroscopy using a single-balloon technique for difficult colonoscopy.  Endoscopy. 2006;  38 395-398