Diagnostic and Therapeutic ERCP in Long-Limb Surgical Bypass Patients Using a New Single-Balloon Assisted Enteroscope

Abstract

Background: Successful per-oral ERCP has been reported in long-limb surgical bypass patients, including Roux-en-Y cases, using standard push enteroscopes (Howell, GIE 1996;43: 383AB). Newer bypass procedures have resulted in increased length of bypass limbs preventing endoscopic access with standard equipment. The single-balloon overtube assisted enteroscope (SBAE)(Olympus America) has recently been released. We report initial experience performing per-oral ERCP using SBAE. Patients and Methods: 10 procedures were attempted in 8 pts, with the following long-limb bypasses: Pylorus preserving Whipple (PPW) (n=2) and bariatric laparoscopic Roux-en-Y gastric bypass (RNYGB) (n=8). Four pts (2 PPW and 2 RNYGB) had a previous failed attempt with other endoscopes, including variable stiffness colonoscopes and standard-push enteroscopes with non-balloon overtubes. Indications: All procedures were carried out with the new Olympus Q180 200cm SBAE. Cannulation and therapy was performed with special enteroscope length accessories supplied by various companies. Indications included: common duct stone (n=1), ampullary stenosis/SOD Type I (n=1), recurrent pancreatitis (n=2), severe right upper quadrant (RUQ) pain with dilated ducts (n=2), chronic pancreatitis (n=2), and PD stent removal (n=2). Results: 8/10 (80%) procedures were successful in reaching the RUQ and assessing the desired duct. Two failures were due to adhesions in one PPW patient and inability to advance beyond the ligament of Treitz in a RNYGB patient. Two diagnostic ERCPs noted a normal cholangiogram in one and extensive pyloric channel ulcer disease in the other. Six therapeutic ERCPs included biliary sphincterotomy (n=1), pancreatic sphincterotomy with stent placement (n=2), biductal sphincterotomy with nasopancreatic drainage (n=1), and pancreatic stent removal (n=2). Complications included a single episode of delayed mild pancreatitis. Both barbless pancreatic duct stents failed to pass after 3 weeks requiring a second SBAE ERCP with successful removal. Experience is ongoing. Conclusions: Single-balloon assisted enteroscopy permitted access to the RUQ in most patients in this initial experience. Diagnostic and therapeutic ERCP was accomplished in all cases where the RUQ was reached. Technical challenges include the front-viewing nature of the enteroscope, the absence of an elevator and the limited selection of therapeutic accessories. Routine per oral ERCP in post-operative long-limb bypass patients should be routinely possible, at least in specialized centers of excellence.