Single-balloon Enteroscopy-assisted Endoscopic Retrograde Cholangiopancreatography Research Articles

Endoscopic Management of Biliary and Pancreatic Pathologies in Roux-en-Y Gastric Bypass Patients: Development of a Treatment Algorithm Based on 9-Year Experience.

Management of biliopancreatic pathology in Roux-en-Y gastric bypass (RYGB) patients is challenging despite the availability of multiple approaches like single-balloon enteroscopy-assisted ERCP (SBE-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and EUS-directed transgastric intervention (EDGI). We evaluated the outcomes of the interchangeable combination of endoscopic procedures to treat biliopancreatic pathology in RYGB patients. This is a monocentric retrospective study of consecutive RYGB patients with biliopancreatic pathology between June 2014 and September 2023. Primary endpoints were technical success, adverse events (AE), and parameters of endoscopic procedures according to etiology. A clinically useful management algorithm was developed. A total of 102 patients with RYGB (73 women; mean age 55 ± 10years) were included. A total of 113 SBE-ERCP (in 90 patients), 26 EDGI (in 23 patients), and 2 LA-ERCP (in 2 patients) were performed. Technical success of SBE-ERCP was lower compared to EDGI (74.4% vs 95.1%, p = 0.002). The AE rate was lower using SBE-ERCP compared to EDGI (12.4% vs 38.5%, p = 0.003). Two sub-groups based on etiology were identified as "common bile duct stone" (CBDS) and "Other." In the CBDS group, the mean number and time of procedures were lower in SBE-ERCP as the first-line technique compared to first-line EDGI (1.1 vs 2.7, p < 0.00 and 91 ± 20.7min vs 161 ± 61.3min, p < 0.00). A combination of endoscopic procedures can achieve high technical success in managing biliopancreatic pathology in RYGB patients with an acceptable AE rate. In the case of CBDS, SBE-ERCP appeared to be a good first-line single-step option. For other indications, EDGI should be proposed as the first line.

Mechanistic Loop Resolution Strategy for Short-Type Single-Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Roux-en-Y Reconstruction

Mechanistic Loop Resolution Strategy for Short-Type Single-Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Roux-en-Y Reconstruction

The Usefulness of the Alpha-Retroflex Position in Biliary Cannulation on Single-Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Roux-en-Y Gastrectomy: A Retrospective Study.

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is a useful therapeutic procedure that provides promising results in patients with surgically altered anatomy. However, biliary cannulation in BE-ERCP remains challenging. Therefore, in patients with Roux-en-Y gastrectomy, this study aimed to evaluate a BE-ERCP cannulation strategy that includes the newly developed alpha-retroflex scope position. This was a retrospective review of 52 patients with Roux-en-Y gastrectomy who underwent BE-ERCP at two centers between April 2017 and December 2022. In these patients, three types of scope position had been used for biliary cannulation: straight (S-position), J-retroflex (J-position), and alpha-retroflex (A-position). First, the S-position was used for biliary cannulation. Then, if biliary cannulation was difficult with this position, the J-position was used, followed by the A-position, if necessary. The biliary cannulation success rate was 96.6% (50/52). The S-, J-, and A-positions achieved successful biliary cannulation in 24 (48%), 14 (28%), and 12 patients (24%), respectively. No adverse events, including post-ERCP pancreatitis and perforation, occurred. This was the first study of a cannulation strategy that included the A-position in addition to the S- and J-positions. The study showed that the A-position is feasible and safe in BE-ERCP in patients with Roux-en-Y gastrectomy.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

BackgroundEndoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. MethodsWe retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. ResultsBiliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76 (90%) procedures and clinical success rate of 30/34 (88%) patients. Mild adverse event rate was 8/76 (11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30 (80%) procedures (P = 0.194 vs. biliary SBE-ERCP) and clinical success rate of 11/17 (65%) patients (P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30 (20%) (P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. ConclusionsBiliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a technical review.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

Status of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: Systematic review and meta-analysis on biliary interventions.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is still challenging. Usefulness of single-balloon enteroscopy (SBE)-assisted ERCP has been increasingly reported. Short SBE is considered beneficial with a 152-cm working length and a 3.2-mm working channel. This has increased the variety of devices that can be used during ERCP procedures. The aim of this pooled analysis was to evaluate the efficacy of SBE-assisted ERCP in patients with surgically altered anatomy and elucidate the current status. This systematic review only involved biliary interventions which excluded pancreatic cases. Studies involving SBE-assisted ERCP in patients with Roux-en-Y gastrectomy, hepaticojejunostomy with Roux-en-Y, pancreaticoduodenectomy (Whipple or Child procedure), or Billroth II gastrectomy were analyzed. Enteroscopy, biliary cannulation, and procedural success were assessed by pooling data in a random-effect model, according to the degree of heterogeneity, to obtain a proportion with 95% confidence interval (CI). The outcomes observed for conventional and short SBE cases were also reported. Overall, 1227 SBE-assisted ERCP procedures from 21 studies were included. The pooled enteroscopy, biliary cannulation, and procedural success rates were 86.6% (95% CI, 82.4-90.3%), 90% (95% CI, 87.1-92.5%), and 75.8% (95% CI, 71.0-80.3%), respectively. Adverse events occurred in 6.6% (95% CI, 5.3-8.2%) of the procedures. Although good outcomes were reported for short SBE-assisted ERCP, these should not be directly compared to the outcomes observed for conventional SBE, as they assume different backgrounds and include confounding variables. Single-balloon enteroscopy-assisted ERCP in patients with surgically altered anatomy on biliary interventions is effective.

The safety and efficacy of self-expandable metallic stent placement for malignant biliary obstruction with surgically altered anatomy

Background Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) has been increasingly performed for the treatment of malignant biliary obstruction (MBO) in patients with surgically altered anatomy (SAA), however evidence is scarce. Therefore, we conducted this study to evaluate the efficacy and safety of self-expandable metallic stent (SEMS) placement using a short type SBE. Methods We retrospectively examined consecutive patients with SAA who received initial SEMS for MBO at our institution between February 2016 and February 2019. We evaluated patient characteristics, technical and functional success rates, time to recurrent biliary obstruction (TRBO) and complications according to the location of the biliary stricture. Results A total of 26 patients were included in this study. The primary tumor was gastric cancer in 12, pancreatic cancer in 6, cholangiocarcinoma in 6 and gallbladder cancer in 2. The biliary stricture site was distal bile duct in 14, hilar bile duct in 3 and hepaticojejunostomy (HJ) anastomosis in 9. Technical and functional success rates were 92 and 88%, respectively. TRBO, median survival time, overall rate of RBO and early complications were not different according to the stricture site (p=.36, .67, .67 and .12, respectively), whereas late complications were significantly different among the three groups (Distal vs. Hilar vs. HJ anastomosis; 0 vs. 67 vs. 22%, p<.05). Furthermore, stent patency was not different between fully covered and uncovered SEMS in distal MBO. Conclusions SEMS placement via SBE-ERCP was safe and effective for the management of MBO in patients with SAA, especially in distal MBO.

Portal vein guidewire insertion: Rare complication of wire-guided cannulation during single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography.

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Single-balloon enteroscopy-assisted ERCP in patients with Roux-en-Y anatomy and choledocholithiasis: do technical improvements mean better outcomes?

endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy is challenging. Single-balloon enteroscopy-assisted ERCP (SBE-ERCP) is an innovative alternative to reach the bile duct. to report our experience in SBE-ERCP in patients who presented with Roux-en-Y anatomy and choledocholithiasis. patients who presented choledocholithiasis and underwent SBE-ERCP between January 2018 and April 2020 were retrospectively identified via medical records and the digestive endoscopy database. Enteroscopy success was defined as reaching the biliary limb and papilla identification. ERCP diagnostic success was defined as a successful duct cannulation and cholangiography, and ERCP procedural success was defined as the ability to successfully carry out choledocholithiasis extraction. Complications of ERCP were defined according to standard criteria. a total of eleven patients (two females) with a mean age of 81 years (range 60-91 years) with Roux-en-Y anastomosis underwent ERCP using a SBE on 13 occasions. The indication for all procedures was choledocholithiasis, which had been previously confirmed by magnetic resonance cholangiopancreatography (MRCP). Enteroscopy success occurred in 13/13 (100 %) of procedures. Overall ERCP diagnostic success was achieved in 11/13 (84.6 %) of procedures. The ERCP procedural success was obtained in 11/11 (100 %) of patients (84.6 % of procedures). A mild pancreatitis occurred in a patient with native papilla. SBE-ERCP is feasible, efficacious and safe in patients with postsurgical Roux-en-Y anatomy and choledocholithiasis. Technical improvements may mean better outcomes.

Biliary Metal Stent Placement During Single-Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography: A Novel Stent Delivery System to Address Surgically Altered Anatomy

Biliary Metal Stent Placement During Single-Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography: A Novel Stent Delivery System to Address Surgically Altered Anatomy

A Retrospective Review of Single-Balloon-Assisted Endoscopic Retrograde Cholangiopancreatography Procedures for Patients With Altered Upper Gastrointestinal Anatomy

Introduction: Management of patients with disorders of the biliary tract following surgical alteration of the upper gastrointestinal (UGI) anatomy offers many challenges. A single-balloon enteroscopy assisted endoscopic retrograde cholangiopancreatography (SBA-ERCP) technique has been described as an effective means of gaining access to the biliary tract in these cases. Methods: We performed a retrospective chart review of patients who underwent at least one SBA-ERCP at a single, tertiary care, academic institution between 2007 and 2014. Our primary endpoint was the rate of successful cannulation of the biliary or pancreatic orifice during each patient's initial procedure. We aimed to identify factors that allowed for successful intervention. Results: We identified 43 patients for analysis. The biliary orifice was successfully cannulated for 28 of these patients (65.1%). Surgical procedures leading to alterations in UGI anatomy included liver transplantation (N=11, 25.6%), Whipple procedure (N=10, 23.3%), roux-en-Y gastric bypass (N=9, 20.9%), Billroth II procedure (N=1, 2.3%), and roux-en-Y hepaticojejunostomy (N=12, 27.9%). Indications for these procedures included acute cholangitis (N=10, 23.3%), hyperbilirubinemia (N=17, 39.5%), severe abdominal pain (N=18, 41.8), biliary injury (N=1, 2.3%), and recurrent pancreatitis (N=5, 11.6%). Therapeutic interventions performed included biliary balloon sweep (N=9, 32.1%), balloon dilation (N=6, 21.4%), and stent placement (N=8, 28.6%). In 15 cases (34.9%), cannulation of the biliary tract was not achieved due to looping of the endoscope (N=4, 26.7%), resistance (N=1, 6.7%), inability to navigate sharp turns (N=2, 13.3%), inability to visualize the biliary orifice following advancement to the end of the proximal limb (N=4, 26.7%), and inability to cannulate following successful visualization of the orifice (N=5, 33.3%). Patients with prior roux-en-Y gastric bypass were noted to have a significantly lower rate of successful biliary tract cannulation (P=0.005, see Table). A major complication of small bowel perforation requiring surgical intervention was noted in one case, and post-ERCP pancreatitis was noted in one case. Conclusion: SBA-ERCP is a challenging procedure with many pitfalls, particularly in patients who have undergone roux-en-Y gastric bypass. SBA-ERCP can offer minimally invasive treatment for biliary disorders in patients with complex anatomy when performed by experienced expert endoscopists.Table 1: Comparison of characteristics of successful cannulation with unsuccessful cannulation in SBA-ERCP procedures for patients with altered UGI anatomy

Adult colonoscopy or single-balloon enteroscopy-assisted ERCP in long-limb surgical bypass patients

The aim of this study was to evaluate the usefulness of adult colonoscopy or single-balloon enteroscopy (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in long-limb surgical bypass patients. Retrospective analysis of 16 patients with long-limb surgical bypasses who underwent therapeutic ERCP because of suspected pancreaticobiliary diseases. Small-bowel intubation was performed by peroral adult colonoscopy or SBE. If colonoscopy success was achieved, ERCP was performed subsequently. But in patients using SBE, a small-caliber colonoscope would be used to replace enteroscope if the SBE success was achieved. ERCP was then performed with the conventional accessories. A total of 21 ERCP procedures were performed. Adult colonoscope was used for ERCP in 8 patients with standard Whipple resection consecutively. Colonoscopy success was achieved in 8 of 8 patients (100%), of whom 7 of 8 (87.5%) achieved ERCP success. SBE-assisted ERCP was attempted in other 8 patients with different types of Roux-en-Y anatomy. SBE success was achieved in 7 of 8 patients (87.5%), of whom 4 of 7 (57.1%) achieved ERCP success. The overall success rate of endoscopy and ERCP was 93.8% (15/16) and 68.8% (11/16), respectively. Adult colonoscopy has high success rate for performing ERCP after Whipple resection and should be selected for such patient preferentially. By using the facilitated method for endoscopic interventions at pancreaticobiliary disease after Roux-en-Y reconstruction, SBE-assisted ERCP can be attempted when it is difficult to gain access to the papilla of Vater or bilioenteric/pancreaticoenteric anastomosis and long length ERCP accessories cannot be available.

Single Balloon Enteroscopy (SBE) Assisted Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients with Roux-en-Y Anastomosis

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis is a complex challenge. Long length of afferent limb after an acute angle at the jejunojejunostomy and altered location of the biliary orifice make biliary cannulation difficult. Single balloon enteroscopy assisted ERCP (SBE-ERCP) is a promising alternative to conventional approaches. The purpose of this study was to assess the efficacy and safety of SBE-ERCP in patients with Roux-en-Y reconstruction at a high volume tertiary referral center. This is a retrospective cohort study. All procedures were performed by a single, experienced pancreatobiliary endoscopist. Patient demographics and related clinical data were obtained. The rate of procedure successes and complications were determined. Fourteen patients (nine women) with a median age of 63years (range 35-83years) underwent 22 SBE-ERCP procedures from March 2009 to May 2011. Surgically altered anatomy consisted of Whipple procedure (n=4), hepaticojejunostomy (n=9) and partial gastrectomy (n=1). Indications for SBE-ERCP were obstructive jaundice (n=10), cholangitis (n=7), post-PTC internalization (n=3) and biliary stent extraction/exchange (n=2). The hepaticojejunostomy site (HJS) was reached in 15 (68%) procedures. Successful interventions were performed in 11 (73%) of 15 cases, including balloon dilation of biliary strictures (n=3), insertion of biliary stents (n=7), retrieval of biliopancreatic stents (n=4) and biliary stone extraction (n=4). The mean procedural time for successful interventions was 97.6min (range 73-147min). No procedural complications occurred during the median follow-up of 501days (range 22-1,242days). SBE-ERCP is safe and carries an acceptable success rate in experienced hands.

Mo1453 Gastrostomy-Assisted Transgastric ERCP Is Superior to Single-Balloon-Enteroscopy-Assisted ERCP in Performing Therapeutic Interventions but Is Likely Associated With More Complications in Patients With Surgically Altered Anatomy

Gastrostomy-Assisted Transgastric ERCP Is Superior to SingleBalloon-Enteroscopy-Assisted ERCP in Performing Therapeutic Interventions but Is Likely Associated With More Complications in Patients With Surgically Altered Anatomy Mary Flynn, Bezawit D. Tekola, Bruce D. Schirmer, Peter T. Hallowell, Paul Yeaton, Dawn G. COX, Monica Gaidhane, Vanessa M. Shami, Bryan G. Sauer, Michel Kahaleh, Andrew Y. Wang* Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA; Department of Surgery, University of Virginia, Charlottesville, VA; Carilion Clinic Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA; Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY Background: ERCP in patients with surgically altered gastroduodenal anatomy is often unsuccessful using a duodenoscope or standard enteroscope. Singleballoon-enteroscopy-assisted ERCP (SBE-ERCP) and gastrostomy-assisted transgastric ERCP (TG-ERCP) are effective methods of performing ERCP in patients with altered anatomy, such as Roux-en-Y (RY) gastric bypass (GB), but studies comparing these two modalities are lacking. Aim: To compare the therapeutic efficacy as well as complication rates between TG-ERCP and SBEERCP in patients with surgically altered anatomy. Methods: ICD-9 codes, CPT codes, and endoscopy records at a tertiary-care academic hospital were used to identify patients with surgically altered anatomy who underwent attempted TGERCP or SBE-ERCP from 1/1/01-9/10/12. Prior to TG-ERCP, patients received an open Stamm gastrostomy, after which the tract was left to mature several weeks before ERCP. The gastrostomy was dilated to at least 12 mm prior to advancement of a duodenoscope (TJF-160VF, Olympus), and TG-ERCP was performed using short-wire devices. SBE-ERCP was performed using an enteroscope (SIF-Q180, Olympus), with or without a cap, and an overtube (STSB1, Olympus). Specialized long wires and devices were used. Intention-to-treat analyses for therapeutic ERCP success and complications were conducted by analyzing cases (not patients).Treatment groups were compared using the Fisher’s exact test. Results: 47 patients (59 cases) (median age: 53 years, range: 28-83 years) with surgically altered anatomy were included (Table 1). 29 patients (22 women, median age: 56 years, range: 28-83 years) underwent attempted SBE-ERCP, comprising a total of 35 attempted cases. 18 patients (16 women, median age: 52 years, range: 37-63 years) underwent attempted TG-ERCP, comprising a total of 24 cases. SBE-ERCP reached the ampulla/pancreatic/biliary orifice in the afferent jejunal limb in 77% (27/35) of cases vs. 100% (24/24) in the TG-ERCP group (P 0.017). 80% (28/35) of cases in the SBE group required therapeutic ERCP after diagnostic ERCP vs. 100% (24/24) in the TG group (P 0.035). The therapeutic success rate was 64% (18/28) for SBE-ERCP vs. 96% (23/24) for TG-ERCP (P 0.007) (Figure 1). Complications from SBE-ERCP occurred in 9% (3/35) vs. 38% (9/24) of cases in the TG-ERCP group (P 0.075). Pancreatitis occurred following 9% of SBE-ERCP and 8% of TG-ERCP cases (P NS). Conclusions: TG-ERCP was significantly more effective at enabling therapeutic ERCP as compared to SBE-ERCP in patients with surgically altered anatomy. However, TG-ERCP is limited to patients with RYGB and typically delays therapeutic ERCP. TG-ERCP was also associated with a higher rate of complications, which trended towards statistical significance. In patients with RYGB who require ERCP, and cannot wait for gastrostomy maturation, SBE-ERCP is a reasonable first therapeutic option.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography for treatment of cholangitis in a patient with a Kasai portoenterostomy

Primary therapy for biliary atresia is a surgical hepatoportoenterostomy (Kasai procedure), which has been shown to reduce mortality, but is frequently complicated by ascending cholangitis and the development of biliary cirrhosis. Previously reported therapy for recurrent cholangitis caused by biliary obstruction has included surgical revision and percutaneous biliary drainage, but endoscopic retrograde cholangiopancreatography has not been previously described. Here, we report a patient with recurrent cholangitis after a Kasai procedure and an anastomotic stricture successfully treated with single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. This novel technique could be considered in patients with this common complication of the Kasai procedure and may impact long-term outcomes in this patient population.

Single Balloon Enteroscopy-Assisted ERCP Using Rendezvous Technique for Sharp Angulation of Roux-en-Y Limb in a Patient with Bile Duct Stones

The acute angulation of Roux-en-Y (R-Y) limb precludes endoscopic access for endoscopic retrograde cholangiopancreatography (ERCP) even using a balloon enteroscopy. Here, we describe a case of successful single balloon enteroscopy (SBE)-assisted ERCP using a rendezvous technique in a patient with sharply angulated R-Y limb in a 79-year-old woman who had bile duct stones. Method. At first, a guidewire was passed antegradely through the major papilla after the needle puncture using percutaneous transhepatic biliary drainage technique. A hydrophilic guidewire with an ERCP catheter was antegradely advanced beyond the Roux limb. After a guidewire was firmly grasped by a snare forceps, it was pulled out of the body, resulting that the enteroscope could advance to the papilla. After papillary dilation, complete removal of bile duct stones was achieved without any procedure-related complication. In conclusion, although further study is needed, SBE-assisted ERCP using a rendezvous technique may have a potential for selected patients.