3499 Therapeutic ercp in the setting of long limb surgical bypass: improved success and outcome of therapeutic procedures.

Abstract

INTRODUCTION: We reported initial ERCP experience in 18 long-limb surgical bypasses (Gastrointest Endosc 1998;47: 62-7). Only 6 had intact papillas and only 3 required sphincterotomy (ES). We report additional experience. PATIENTS & METHODS: From 4/93-8/99, 47 pts (male 18, female 29, age 24-80) were referred for consideration of therapeutic ERCP with long-limb surgical bypasses: 8 with gastric bypass; 16 with Whipple's, 11 with hepatojejunostomy; and 12 with post-gastrectomy Roux-en-Ys. Indications: pain (n=26), jaundice (n=17), recurrent or chronic pancreatitis (n=11), suspected CD stones (n=7), and anastomotic bleeding (n=1). An enteroscope was used in 13, a pediatric colonoscope in 17 and a duodenoscope in 17. RESULTS: The papilla or pancreaticobiliary anastomosis was reached in 41 of 47 (87%). The overtube was used with 5 and only in the setting of an intact stomach. 6 failures were due to inability to pass into the afferent limb. 2 failures were due to inability to locate the PD anastomoses. 20 patients had intact papillas (12 with Roux-en-Ys, 8 with gastric bypass). Cannulation failed in 4 of these 20 (20%) due to an inability to align the long front viewing instruments. 7 pts with intact papillas needed ES; 3 methods were used: (1) Following guidewire and temporary stent placement, a stent guided needle-knife ES was used when alignment could be achieved (n=4); (2) A wire-guided B-II type sphinctertome was used (n=1). (3) One patient failing guidewire placement underwent successful needle knife ES only. The final patient required a combined procedure with PTC guidewire placement followed by B-II type ES at a second ERCP. Among the 35 cannulated patients, successful Rx followed in 34: stents in 16 (10 biliary plastic stents, 2 PD stents, 4 Wallstents); biliary dilatation in 6; stone extraction 3; tissue sampling 3; pancreatic dilatation 1; duodenal dilatation 1. In 1 patient, coagulation of a visible vessel required surgical treatment for recurrence. No post-ERCP pancreatitis, bleeding, or perforation was noted. CONCLUSION: Although technically difficult, successful therapeutic ERCP is generally possible with long limb surgical bypasses with a high success rate and a low complication rate. The intact papilla greatly exacerbates these difficulties and occasionally requires percutaneous wire placement for assistance. The development of a colonoscope length, oblique-viewing enteroscope with an elevator should greatly enhance therapeutic ERCP in these patients.