Double Balloon Enteroscopy (DBE) Can Be Routinely Employed to Perform ERCP in Bariatric Gastric Bypass (RYGB) Patients

Abstract

Pancreaticobiliary complaints are common in RYGB patients and are difficult to investigate by ERCP because of a long small bowel limb and lack of special endoscopic equipment. DBE has been effective in performing ERCP in a very small number of patients. Aim: Report on the DBE-ERCP experience in RYGB patients in 6 major U.S. DBE centers. Methods: Retrospective review of the experience of all attempted DBE-ERCP cases in RYGB patients during 1/06-11/07. Results: Two institutions did not perform any procedure and 3 attempted once. One center attempted DBE-ERCP 17 times. Procedure indications: abdominal pain (14), suspected biliary stones (4), obstructive jaundice (1), cholangitis (2), recurrent liver abscess (1) and pancreatitis (4). Patients' mean BMI = 29.7. All patients had intact papillae. The maximum distance reached: stomach (13), duodenum (3), afferent limb (1), jejunojejunostomy anastomosis (2). DBE passage was aborted when a large gastrogastric fistula was found in 1 patient. A duodenoscope was used instead to carry out the ERCP through the fistula. Eleven cases were done with a soft cap at the tip of the scope. Excluding the gastrogastric fistula case, 12 ERCP were considerd technical success, 2 were partial success and 5 were failures (could not reach the duodenum for cannulation-3; failed cannulation-2). The mean total procedure time for those with records was 103 minutes and ERCP alone (from cannulation to completion) took 42 minutes to do. Therapeutic maneuvers: biliary sphincterotomy-12; balloon sphincter dilation-9; clipping of a retroperitoneal perforation-1. Of 16 attempted cannulations, 11 were assisted with a cap and 5 without. There was no significant difference between the 2 groups. 9 successful cannulations were aided by a guidewire and 5 by needle knife precutting. Complications included 1 severe non-pancreatitis abdominal pain and 1 self-limited retroperitoneal perforation. In spite of frequent sphincter dilation (n = 11, all done after a sphincterotomy), no pancreatitis was encountered. In the institution where 17 cases were done, the last 9 attempts were successful and they coincided with the introduction of a self-made cannulation and sphincterotomy device. Conclusions: In spite of increasing demand, DBE-ERCP is exceedingly difficult and is rarely done in RYGB patients. Failure is common, with 16% caused by problems in reaching the major papilla and 11% by failed cannulation. Half of our centers are either unable to or choose not to perform this procedure. But with experience and a modified cannulation/injection/sphincterotomy device, DBE-ERCP can be successfully carried out in most cases.