A Retrospective Review of Single-Balloon-Assisted Endoscopic Retrograde Cholangiopancreatography Procedures for Patients With Altered Upper Gastrointestinal Anatomy

Abstract

Introduction: Management of patients with disorders of the biliary tract following surgical alteration of the upper gastrointestinal (UGI) anatomy offers many challenges. A single-balloon enteroscopy assisted endoscopic retrograde cholangiopancreatography (SBA-ERCP) technique has been described as an effective means of gaining access to the biliary tract in these cases. Methods: We performed a retrospective chart review of patients who underwent at least one SBA-ERCP at a single, tertiary care, academic institution between 2007 and 2014. Our primary endpoint was the rate of successful cannulation of the biliary or pancreatic orifice during each patient's initial procedure. We aimed to identify factors that allowed for successful intervention. Results: We identified 43 patients for analysis. The biliary orifice was successfully cannulated for 28 of these patients (65.1%). Surgical procedures leading to alterations in UGI anatomy included liver transplantation (N=11, 25.6%), Whipple procedure (N=10, 23.3%), roux-en-Y gastric bypass (N=9, 20.9%), Billroth II procedure (N=1, 2.3%), and roux-en-Y hepaticojejunostomy (N=12, 27.9%). Indications for these procedures included acute cholangitis (N=10, 23.3%), hyperbilirubinemia (N=17, 39.5%), severe abdominal pain (N=18, 41.8), biliary injury (N=1, 2.3%), and recurrent pancreatitis (N=5, 11.6%). Therapeutic interventions performed included biliary balloon sweep (N=9, 32.1%), balloon dilation (N=6, 21.4%), and stent placement (N=8, 28.6%). In 15 cases (34.9%), cannulation of the biliary tract was not achieved due to looping of the endoscope (N=4, 26.7%), resistance (N=1, 6.7%), inability to navigate sharp turns (N=2, 13.3%), inability to visualize the biliary orifice following advancement to the end of the proximal limb (N=4, 26.7%), and inability to cannulate following successful visualization of the orifice (N=5, 33.3%). Patients with prior roux-en-Y gastric bypass were noted to have a significantly lower rate of successful biliary tract cannulation (P=0.005, see Table). A major complication of small bowel perforation requiring surgical intervention was noted in one case, and post-ERCP pancreatitis was noted in one case. Conclusion: SBA-ERCP is a challenging procedure with many pitfalls, particularly in patients who have undergone roux-en-Y gastric bypass. SBA-ERCP can offer minimally invasive treatment for biliary disorders in patients with complex anatomy when performed by experienced expert endoscopists.Table 1: Comparison of characteristics of successful cannulation with unsuccessful cannulation in SBA-ERCP procedures for patients with altered UGI anatomy