Double Balloon Enteroscopy (DBE)-Assisted ERCP Following Roux-En-Y Biliary Reconstruction: New Tool for An Old Problem

Abstract

Background: Reported success rates for ERCP in patients after Roux-en-Y biliary reconstruction are mixed, and procedures are most often performed with colonoscopes. Endoscopic difficulties precipitate referral of many patients for percutaneous interventions. Factors which may influence the success rate of endoscopic therapy include the distance of the anastamosis from the ligament of Treitz, angulated entry or adhesions involving the biliary limb, unfavorable gastroduodenal endoscope loops in patients with intact stomachs, and operator experience. Aims: To determine if DBE equipment could be used improve the learning curve and success rate of ERCP in patients after standard length Roux-en-Y biliary reconstruction surgery. Patients and Methods: IRB approved prospective observational study from October 2006 to November 2007 including all patients with presumed biliary obstruction referred to a tertiary academic center for ERCP following roux-en-y biliary reconstruction. Patients with reduced gastroduodenal anatomy and those with short distances from the ligament of Treitz to the roux-en-y anastamosis less than 50 cm were excluded from analysis to avoid confounding variables (in 5 such patients, DBE-ERCP was successful). Ten consecutive patients met criteria, representing the initial attempts at roux-limb ERCP for a forth year advanced endoscopy fellow and a junior attending. Endoscopic equipment included Fujinon EN450T5 enteroscope systems and a shorter Fujinon prototype enteroscope system with a larger working channel. All patients were performed supine under general endotracheal anesthesia. Results: ERCP was successful in 7/10 patients (70%). Therapeutic interventions were performed, including anastamotic dilation and stone extraction, in six of the seven patients where the biliary anastamosis could be identified. 2/3 failures were in the first 3 attempts and occurred with the shorter prototype DBE scope, prompting discontinuation of use of this scope system in subsequent patients. 1/3 failures occurred in a patient with jaundice, where the termination of the biliary limb was reached, but the biliary anastamotic site could not be identified. No complications were noted. Conclusions: DBE technology appears to facilitate ERCP in patients with a history of roux-en-y biliary reconstruction surgery. DBE equipment refinements and education of providers could result in a shift away from reliance on percutaneous therapy for such patients.