The Utility of Overtube Assisted Enteroscopy Using the Single Balloon Overtube for Retrograde Afferent Limb Access After Roux-en-Y Gastric Bypass

Abstract

Introduction: Bariatric surgery is now a frequent procedure due to the high prevalence of obesity in the United States. Gastroenterologists are frequently involved in the post-surgical care of these patients. The most commonly performed permanent surgery is Roux-en-Y gastric bypass (RYGBP) in which a small and separate gastric pouch is created and connected to a jejunal Roux limb. The duodenal afferent limb is connected to the Roux limb at variable distances, making it difficult to endoscopically access the afferent limb and remnant stomach. Overtube assisted enteroscopy has improved the ability to achieve deep small bowel intubation even in patients with surgically altered anatomy. We describe our experience using single balloon enteroscopy (SBE) in RYGBP patients to access the afferent limb and remnant stomach. Methods: The small bowel endoscopy database was searched and patients who had a RYGBP operation and underwent SBE were included. SBE was performed using the Olympus system (SIF-Q180, Olympus Optical Co., Ltd., Tokyo, Japan) which consists of a 200-cm long video endoscope with an outer diameter of 9.2 mm and a flexible overtube with a length of 140 cm and an outer diameter of 13.2 mm with a single inflatable balloon at the tip of the overtube. Standard procedure for insertion and advancement of the SBE was used with inflation, deflation, and reductions resulting in plication of the small bowel. Results: 7 patients (6 females, 1 male) with gastric RGYBP performed for obesity underwent SBE with a mean age of 44 yrs (SD ± 18 yrs). Indications for enteroscopy included unexplained abdominal pain (n = 4), gastrointestinal bleeding (n=1) and attempted ERCP (n=2). SBE was performed under propofol sedation in six patients and sedation with versed and fentanyl in one patient. Mean duration of the entire procedure was 62 minutes (SD ± 30 minutes). The entero-enteral (or jejuno-jejunal) anastomosis was easily reached and the afferent limb was entered in all patients. The remnant stomach was entered by the retrograde technique in five patients and a benign gastric ulcer was noted in one patient who had previous gastrointestinal bleeding. Of the two patients requiring ERCP, the ampulla could not be reached in one patient. However, successful ERCP with sphincterotomy was performed in the other patient for papillary stenosis. No complications resulted from any of the endoscopic procedures. Conclusions: SBE appears to be safe and effective for use in patients who have undergone RGYBP to access the afferent limb and remnant stomach for diagnostic and therapeutic purposes. Moreover, the ability to reach the ampulla makes ERCP possible in these patients.