Endoscopic Retrograde Cholangiopancreatography Using Balloon Assisted Enteroscopes in Patients with Roux en Y Anatomy

Abstract

Purpose: Roux en Y reconstruction can be found in patients with gastric bypass (RYGBP), hepaticojejunostomy (HJ), and pancreaticojejunostomy (PJ). The altered anatomy poses challenges in endoscopy when attempting to access the pancreas or bile duct. The use of balloon assisted enteroscopes to perform endoscopic retrograde cholangiopancreatography (ERCP) has become an option in centers equipped with both capabilities. Herein we describe our experience in this combined procedure.Table: [146]Methods: All enteroscopy assisted ERCP were retrieved from our Endoscopy Database. Procedures were performed by two experienced endoscopists: KBH for single (SBE) or double balloon enteroscopy (DBE) and FAK for ERCP. Seven patients, all females, had a total of twelve procedures: two using the DBE and ten using the SBE were performed between September 2009 and May 2010. All records were reviewed for indication, success to reach the ampulla or biliary/pancreatic anastomosis, and the ability to accomplish therapeutic intent. Results: The major papilla/anastomosis was reached in 10 of 12 cases (83%), with procedure times ranging from 9 to 143 minutes. Cannulation was achieved in 8 of 10 (80%), and intervention was accomplished in all 8 cases, ranging from stricture dilation, stent placement, to stent removal. Cannulation of the bile duct was not possible in two patients with a native ampulla. One of the failed cannulations had a successful ERCP using the transgastric approach (patient 6) while the other had a successful subsequent ERCP (patient 4). Times for the ERCP portion ranged from 32 to 109 minutes, with total combined procedural times ranging from 41 to 189 minutes. The most common problem encountered was advancing accessories through the scope. The use of prototype accessories (Olympus corporation) allowed for needle knife sphincterotomy, balloon dilation, and stent placement in one of the procedures (patient 4). The major procedure related complication was abdominal pain. No patients developed pancreatitis. Conclusion: Balloon assisted enteroscopy for ERCP is a viable safe option for patients with Roux en Y anatomy requiring pancreaticobiliary interventions. Failure is more common in patients with an intact ampulla. Major limitations are loop formation, the short length of many commonly used accessories, and lack of an elevator on the enteroscope. Increasing experience and improvements in scopes and accessories will most likely increase the success rate of the procedure. Laparoscopy assisted ERCP continues to be an option for those who fail the enteroscopy assisted option.