Abstract
Purpose: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered gastroduodenal anatomy is challenging. Long length of afferent limb and altered location make selective cannulation of the hepaticojejunostomy site (HJS) difficult. Single-balloon enteroscopy (SBE) is a new modality that uses a single-balloon splinting overtube to sequentially reduce and pleat the small bowel over a standard enteroscope, and enables negotiation of acute angulations sometimes found at gastroenteric or enteroenteric anastomoses. A few case-series reported SBE assisted ERCP is promising for replacing conventional approaches, push enteroscopy or percutaneous transhepatic cholangiography (PTC). The aim of this study is to assess the efficacy and safety of SBE assisted ERCP in patients with surgically altered anatomy in a high volume tertiary referral center. Methods: This is a retrospective cohort study. All procedures were performed by a single experienced pancreatobiliary endoscopist. Patient demographics and all the related clinical data were obtained from hospital record. Overall success rate of completion of procedure is measured as main outcome. Procedure-related complications were also assessed. Results: Fifteen patients (5 men, 10 women) with a median age of 62 years (range 35-83 years) underwent 22 SBE procedures from March 2009 to May 2011. Surgically altered anatomy consisted of Whipple procedure with Rouxen-Y (n = 12) and hepaticojejunostomy with Roux-en-Y (n = 3). ERCPs were initially performed for obstructive jaundice (n = 10), cholangitis (n = 3), cholangitis with liver abscess (n = 1), and post-PTC internalization (n = 1). Additional procedures were conducted for post-PTC internalization after initial failure of SBE-ERCP (n = 4), stent exchange (n = 2), and biopsy for stenosis (n = 1). The HJS was reached in 15 (68.2%) of 22 procedures. Failure cases of HJS detection were complete malignant luminal occlusion (n = 2), excessive looping of endoscope (n = 4), and inability to recognize HJS (n = 1). Therapeutic ERCP was required in 11 cases in whom the HJS was reached and successfully performed in 7 cases (63.6%), including balloon dilation (n = 2), balloon dilation plus stenting (n = 2), and stenting (n = 3). The mean procedural time from scope insertion to scope withdrawal for all procedures attempted and successful interventions were 80.7 minutes (range 42-126 minutes) and 95.6 minutes (range 73-126 minutes), respectively. Median follow-up was 61 days (range 30-570 days) and no procedural complications occurred. Conclusion: SBE assisted ERCP is safe and carries an acceptable success rate in experienced hands.
Published Version
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