7243 Endoscopic retrograde cholangiopancreatography (ercp) in roux-en-y anastomosis or whipple surgery patients: eight-year experience from a large tertiary care center.

Abstract

Reaching major papilla and performing cannulation of the pancreatic and bile duct in the setting of Roux-en-Y anastomosis or Whipple surgery is considered one of the most technically challenging anatomic variants in patients (pts) with symptomatic pancreaticobiliary disease. AIM: To describe eight-year ERCP experience in Roux-en-Y anastomosis or Whipple surgery pts from a large tertiary care center. METHODS: Nineteen consecutive pts (10-male, 9-female, age range 38-79) with Rouxen-Y anastomosis or Whipple surgery presented over a eight-year period had an attempted ERCP. Thirteen (70%) of pts had Roux-en-Y anastomosis while 6 pts had undergone Whipple surgery. Indications for ERCP were obstructive jaundice (n=5), cholangitis (n=3), suspected choledocholithiasis (n=5), abdominal pain (n=3), dilated pancreatic duct (n=2), and chronic pancreatitis (n=1). RESULTS: Successful bile duct cannulation could be achieved in only 8 (47%) of the 17 pts. Six out of 13 (46%) Roux-en-Y anastomosis pts had successful ERCP (5 of 6 with the use of diagnostic duodenoscope),while only 2 out of 6 (33%) Whipple surgery pts had successful ERCP. Major papilla could not be reached in 8 pts (88%) in whom ERCP was unsuccessful. In one patient with Whipple surgery a pancreatogram could not be obtained because of inability to locate enteropancreatic anastomosis. Two Roux-en-Y anastomosis pts who had successful cannulation, common bile duct stones were removed, one patient with Whipple surgery had a plastic stent placed across a choledochojejunostomy stricture, one patient with a Roux-en-Y anastomosis underwent sphincter of Oddi manometry and in one Roux-en-Y anastomosis patient a plastic stent was placed in an occluded wallstent. Diagnostic duodenoscope was the most commonly used instrument (n=11), followed by pediatric colonoscope (n=7). One patient had a small intestinal perforation requiring surgery. All pts with obstructive jaundice and cholangitis (n=5) who had unsuccessful ERCP underwent subsequent successful percutaneous transhepatic biliary drainage. Conclusions: Success rate in performing ERCP in Roux-en-Y anastomosis or Whipple surgery pts is low despite a high level of endoscopic expertise. Both side viewing duodenoscopes and forward viewing colonoscopes can be used in an attempt to reach the major papilla in pts with Roux-en-Y anastomosis, although the instrument of choice remains the former.