SEARCH

SEARCH BY CITATION

Keywords:

  • balloon-assisted endoscope;
  • Billroth II gastrectomy;
  • double balloon endoscope;
  • endoscopic retrograde cholangiopancreatography (ERCP);
  • Roux-en Y reconstruction

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

Endoscopic treatment for pancreatobiliary diseases is less invasive than surgery and percutaneous transhepatic biliary drainage is highly beneficial to patients. The endoscopic approach is indicated for an increasing number of patients, including those who have undergone previous gastrointestinal surgery, although these patients face two major challenges. First, the endoscopic approach to the afferent loop, blind end, and the site of choledochojejunostomy is difficult with the use of a conventional endoscope because of the distance from the gastrojejunal anastomosis site, unusual anatomical features of the intestine such as its winding shape, and postoperative adhesion. Second, it is difficult to reach Vater's papilla or the site of choledochojejunostomy andto cannulate selectively into the pancreatic and/or biliary duct. The balloon-assisted endoscope (BAE), a recently developed technology, can be useful for carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. ERCP using the BAE is highly effective and safe in patients with altered gastrointestinal anatomy, especially in patients with Roux-en-Y reconstruction.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

Endoscopic retrograde cholangiopancreatography (ERCP) has been widely applied to pancreatobiliary disease cases in which patients have not undergone gastric or pancreatobiliary surgical operations. The success rate is 90–95%.[1, 2] It has been quite challenging to carry out conventional ERCP for pancreatobiliary diseases in patients with altered gastrointestinal anatomy. Success depends on the method of surgical operation, but many cases are unsuccessful.[3] The most common reasons for lack of success are the inability of the endoscope to reach the ampulla, surgical pancreatobiliary anastomosis as a consequence of the length of the bowel passage, and severe angulation that cannot be traversed safely – some acute angles of surgical limbs are difficult to navigate. As a result, many patients with altered gastrointestinal anatomy are referred for surgical or percutaneous interventions, which have greater complications than endoscopic therapy.[4]

Percutaneous transhepatic cholangiography (PTC) may be limited technically because of the absence of dilated intrahepatic ducts or may be contraindicated because of ascites or compromised coagulation. Additionally, PTC does not allow access to the pancreatic duct system,[4] leaving surgery as the only alternative.[5] Open surgery brings about greater morbidity, longer hospitalization, and increased costs. Therefore, the endoscopic approach is preferred. During the late 1990s and early 2000s, multiple studies reported success rates from 50% to 92% for ERCP by using standard side-viewing duodenoscopes or enteroscopes in patients with Billroth II anatomy.[3, 6-8]

The success rate in patients with Roux-en-Y ranges between 33% and 67%,[8, 9] which indicates that cases with Roux-en-Y reconstruction are more challenging. Thus, some endoscopists have attempted to carry out ERCP in patients with Roux-en-Y surgical reconstruction using pediatric- or adult-use colonoscopes, enteroscopes,[8-12] and oblique-viewing endoscopes with an overtube.[13] Unfortunately, the endoscopic approach was not practically useful or satisfactory in such patients. The recent development of the balloon-assisted endoscope (BAE) has enabled more practical use of diagnostic and therapeutic ERCP.

Surgically Altered Anatomy

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

Today, the surgically altered anatomies more frequently encountered in the USA are Roux-en-Y gastric bypass (RYGB) for morbid obesity,[14-17] hepaticojejunostomy for living donor liver transplantation (LDLT)[18, 19] or treatment of biliary injury or disease,[20, 21] and pancreaticoduodenectomy for pancreatic carcinoma and ampullary neoplasia.[22, 23] In Japan, total or partial gastrectomy for treatment of gastric disease and pancreaticoduodenectomy for treatment of pancreatic carcinoma are frequently encountered. RYGB for morbid obesity and hepaticojejunostomy for LDLT are rarely encountered in Japan. For gastrectomies, Billroth II reconstruction has decreased as a result of the effective treatment of peptic ulcer disease, and Roux-en-Y reconstruction has increased as a result of the recent spread of laparoscopic surgery. For pancreaticoduodenectomies, modified Child surgery is most commonly applied. In our hospital, between February 2006 and February 2013, we carried out DBE-assisted ERCP in 269 patients (473 procedures) with various anatomical variations. The variations of surgical anatomical reconstruction are shown in Table 1.

Table 1. Bowel reconstructions at Kansai Medical University Hospital
Roux-en-Y reconstruction248 procedures (141 patients)
Billroth II reconstruction95 procedures (60 patients)
Pancreatoduodenectomy65 procedures (31 patients)
Pylorus-preserving pancreatoduodenectomy40 procedures (21 patients)
Other25 procedures (16 patients)

Endoscopes

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

The advent of the deep endoscope has revolutionized the management of patients with mid-small-bowel diseases. Since the introduction of the DBE by Yamamoto et al. in 2001, two additional techniques have become available: single-balloon endoscope (SBE) and spiral endoscope (SE).[24-26] DBE and SBE entail a similar mechanism of advancement consisting of sequential bowel pleating by a push-pull technique that uses a balloon-fitted overtube with or without a second balloon inserted over the tip of a dedicated endoscope. In contrast, SE, or the rotational endoscope, uses a spiral or raised helix-fitted overtube coupled with the endoscope. This is advanced as a unit into the small bowel by continuous rotation of the overtube in a manner similar to the use of a corkscrew. The main difference between the balloon endoscope and the spiral endoscope is that the latter uses a more or less continuous pleating of the small bowel by a clockwise rotation of the overtube rather than the push-pull technique.[27] Using either technique allows the use of the endoscopic approach for pancreatobiliary diseases in patients with altered gastrointestinal anatomy, which had been difficult before. BAE that are currently commercially available in Japan are shown in Table 2.

Table 2. Balloon-assisted endoscopes that are currently commercially available in Japan
 FUJIFILMOlympus Medical Systems
EN-450P5/20EN-450T5EC-450BI5EI-530BSIF-Q260
  1. FUJIFILM, Osaka, Japan; Olympus Medical Systems, Tokyo, Japan.

Outer diameter (mm)8.59.49.49.49.2
Total length (mm)23002300182018202345
Working length (mm)20002000152015202000
Accessory channel (mm)2.22.82.82.82.8

BAE Instruments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

The long-type DBE, EN-450T5 (FUJIFILM, Osaka, Japan), has a 2.8-mm working channel and a 200-cm working length. The short-type DBE, EC-450BI5/EI-530B (FUJIFILM), has a 2.8-mm working channel and a 152-cm working length. The SBE, SIF-Q260 (Olympus Medical Systems, Tokyo, Japan), has a 2.8-mm working channel and a 200-cm working length and does not have a balloon at its tip. Because the working lengths of the long-type DBE and the SBE are 200 cm, availability of ERCP-related devices is limited because of the lack of commercially produced long accessories in Japan. The short-type DBE can be used with almost all the standard ERCP devices. This is advantageous for ERCP-related interventions.

The working channel of all these BAE is 2.8 mm, which sometimes poses challenges because pushing in and pulling out the devices must be done very tightly, causing much stress. Formerly, only short-type DBE were available, although, recently, the short-type SBE has been developed.[28] The significant feature of the short-type SBE is that it has 3.2 mm as its working channel, which enables almost all conventional ERCP devices to be used, including the covered metallic stent. In the future, we expect more development of endoscopes and ERCP devices.

Entering the Afferent Limb

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

The first report of ERCP in long-limb anastomoses was in 1988,[12] when a pediatric colonoscope was used to carry out the procedure in three patients; colonoscopies[11] and standard duodenoscopes have been used in subsequent cases. In one study, the success rate of reaching the ampulla was 33% in Roux-en-Y anastomoses, compared with 92% in Billroth II anatomy.[8]

Since 2007, more studies of DBE-assisted ERCP have been reported. In 2009, studies of ERCP using SBE were introduced. Compared to results from before the advent of BAE, the success rate improved to a satisfactory level. Still, there are several challenges for deep insertions of BAE into the blind end. The first challenge is identification of the afferent limb. Especially in cases of Roux-en-Y reconstruction, it is very difficult to identify the afferent limb in jejunojejunal anastomosis, which is maze-like and causes endoscopists to lose their way. Recently, Yano et al.[29] reported using an intraluminal injection of indigocarmine to identify the afferent limb, a method that had a success rate of 80%. This method may be useful in the identification of the afferent limb.

The second challenge is angulation of the jejunojejunal anastomosis and the long length of the afferent limb. The challenges endoscopists encounter are managing the sharp angulation of jejunojejunal anastomosis in order to access the afferent limb, which in some patients forms an angle of up to 180 degrees, and insertion to the blind end. Regarding the length of the afferent limb, RYGB for morbid obesity, which is mainly carried out in the USA, is a particularly challenging post-surgical anatomy because of the long limb (often >100 cm) that must be traversed from the gastrojejunal orifice to the jejunojejunal anastomosis to reach the afferent small-bowel limb.[9] The RYGB is seldom done in Japan. We assume that in gastrointestinal anatomy, the primary disease and the operation method differ to some extent between the USA and Japan.

The third challenge is adhesion. In Japan, cleaning of regional lymphatics of malignant tumors is more likely to be performed, which, in many cases, results in post-surgical hard adhesion. In most cases, adhesion is observed in patients with altered gastrointestinal anatomy, which often becomes an obstacle for the advancement of the endoscope. Insertion into this site by force increases the risk of bleeding and perforation. Therefore, special care should be taken, and endoscopists should have discretion to withdraw.

BAE-ERCP Technique

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

Positioning and selective biliary cannulation

Intact papilla

In cases with Billroth II reconstruction, once the endoscope reaches the papilla, it will be recognized in the upper-left side of the monitor. Deep insertion of the overtube helps to hold and fix the jejunum, which stabilizes the endoscope. Maneuvering the overtube and the endoscope together in an attempt to place the papilla at the 6 o'clock position on the monitor, and using the uncurved-straight cannula makes selective biliary cannulation relatively easy (Fig. 1).

figure

Figure 1. Although the papilla is located at the 11 o'clock position in the visual field (left), the papilla can be moved to the 6 o'clock position by keeping the overtube balloon inflated and rotating the enteroscope (right).

Download figure to PowerPoint

In cases with Roux-en-Y reconstruction, it will often be recognized between the 11 and 1 o'clock positions on the monitor, but may also be located elsewhere. Similar to the cases with Billroth II reconstruction, maneuvering the overtube and the endoscope to place the papilla at the 6 o'clock position should be attempted. A sphincterotome (Autotome RxTM; Boston Scientific, Osaka, Japan) that has a knife that can rotate 360 degrees on the tip can be used to facilitate selective cannulation.

Hepaticojejunal anastomosis

It is important to identify anastomosis in patients with hepaticojejunal anastomosis. Especially with a benign stenosis of the anastomosis, it is important to localize with care because the anastomosis site may form a pinhole-like stenosis (Fig. 2). The ulcer scar-like mucosal pattern around the anastomosis can be a clue in its identification. Hepaticojejunal anastomosis is often seen in the front in the monitor of the endoscope and, if it is found, use of the straight-triple-lumen catheter facilitates cannulation.

figure

Figure 2. Hepaticojejunal anastomosis shows a pinhole-like stenosis. The opening of the hepaticojejunostomy is stenotic (arrow shows the hepaticojejunal anastomosis).

Download figure to PowerPoint

Endoscopic sphincterotomy

Wire-guided endoscopic sphincterotomy (ES) is performed using a pull-type sphincterotome, a needle-knife sphincterotome, or a needle-knife biliary sphincterotomy over a biliary stent. If selective biliary cannulation is possible, the wire-guided pull-type sphincterotome is used. The Clevercut (KD-V411M-3020; Olympus Medical Systems), which has the first half of the cutting wire covered by an insulator, was the first to be used. Once it is modified to the surgeon's preference, it should be oriented into the bile direction. If the tip of the knife will not orient into the biliary direction, then the Autotome described above is used (Fig. 3). If selective biliary cannulation is not possible, a needle knife sphincterotomy (PR-233Q or KD-10Q-1; Olympus Medical Systems) of the papilla is carried out.

figure

Figure 3. Endoscopic sphincterotomy is done with a sphincterotome with a tip rotatable through 360 degrees. Although the tip of the knife is located at the 3 o'clock position in the visual field (left), the tip of the knife can be rotated to the 12 o'clock position (right).

Download figure to PowerPoint

Dilation of hepaticojejunostomy anastomosis

In patients with a hepaticojejunostomy in whom an anastomotic stenosis is identified, a wire-guided balloon dilatation catheter is used for biliary dilation (Fig. 4a). In incidences when the balloon catheter cannot be inserted, a dilation catheter (Soehendra biliary dilation catheter; Cook Medical, Bloomington, IN, USA) is used to serially dilate the stenosis (Fig. 4b).

figure

Figure 4. (a) Hepaticojejunostomy is dilated with an 8-mm balloon catheter (left), and the anastomosis is opened (right). (b) When the balloon catheter could not be inserted, a dilation catheter was used to serially dilate the stenosis.

Download figure to PowerPoint

Endoscopic biliary stone extraction

First, ES using a conventional sphincterotome or EPBD in combination with ES is done to enable a reliable approach to the bile duct. Then, stone extraction is performed. Next, lithotripsy is achieved using a mechanical lithotripter (Crusher Catheter; Xemex, Tokyo, Japan), which is inserted using a guidewire. The Crusher Catheter is a mechanical lithotripter that is currently only available for DBE. It is essential to crush the biliary stones using this device before the extraction (Fig. 5). In BAE-ERCP, difficulty in extracting stones along the axis may be encountered. This differs from conventional ERCP. If stone extraction is done forcefully, it can cause stone impaction and a higher risk of perforation. Special attention must be paid to this procedure.

figure

Figure 5. Mechanical lithotripter is inserted using a guidewire (left), resulting in successful stone extraction (right).

Download figure to PowerPoint

Recently, endoscopic papillary large balloon dilation (EPLBD) (Boston Scientific Japan, Tokyo, Japan) has been applied, which makes it possible to carry out stone extraction more easily and safely than in the past (Fig. 6). Furthermore, EPLBD is most often indicated in cases with post-surgical anatomy where retrograde cholangitis seldom occurs, because food does not usually pass into the blind end.

figure

Figure 6. Endoscopic papillary large balloon dilation is done for giant stone extraction.

Download figure to PowerPoint

Drainage

In cases of biliary or pancreatic ductal obstruction from a benign or malignant stricture, plastic or metallic stents are placed across the stenosis under wire guidance. Metallic stents are inserted for inoperable malignant biliary stenosis (Fig. 7). Because the diameter of the working channel is 2.8 mm, available metallic stents are limited. However, if an endoscope with a working channel of 3.2 mm is used, various stents are available for insertion.

figure

Figure 7. Metallic stent is placed transpapillary for malignant biliary stricture.

Download figure to PowerPoint

DBE-assisted ERCP

There have been many studies on DBE-assisted ERCP and the results vary widely. Success rates for deep insertion to the blind end range from 60 to 100%; the success rate of ERCP-related interventions is 60–100%,[30-48] which is probably because many studies have reported on a small number of cases. Regarding treatments such as stone extraction, balloon dilation of the ampulla or common bile duct, endoscopic sphincterotomy, placement of plastic and metallic stents, endoscopic nasobiliary drainage tubes and so on, almost all the treatments are carried out as frequently as conventional ERCP.

As a single center study, we have reported a large case study (103 procedures on 68 patients). In our report,[46] we evaluated Roux-en-Y reconstruction and various other reconstruction methods. The overall success rate for ERCP was 95% (based on success rates for Roux-en-Y reconstruction, Billroth II reconstruction, and pancreatoduodenectomy of 91%, 100%, and 100%, respectively). In all successful ERCP cases, we were able to carry out endoscopic therapeutic interventions. Details of the treatments which are performed with DBE-assisted ERCP equivalent to those with conventional ERCP.

Recently, several multicenter studies have been reported in the USA. One report, which focused only on Roux-en-Y reconstruction using several enteroscopes, observed 180 procedures (129 patients).[47] The success rate for reaching the blind end was 71%, and for cannulation, the success rate was 88%. The overall success rate for ERCP was 63%. ERCP success rates were similar between Roux-en-Y gastric bypass and other long-limb surgical bypasses for SBE and DBE. Regarding type of endoscope, the overall success rates for ERCP were: SBE 60%, DBE 63%, and SE 65%. Regarding reaching the blind end, the success rates were: SBE 69%, DBE 74%, SE 72%; and for cannulation, the success rates were: SBE 87%, DBE 85%, and SE 90%. Our success rate for ERCP was higher, which we assume is because our study was done in a single center. A second multicenter report, which focused on ERCP using the short-type DBE for various anatomical variations, observed 79 patients.[48] The overall success rate for DBE-assisted ERCP was 90%. The success rate of reaching the blind end was 89% (based on success rates of 82% for Roux-en-Y gastric bypass, 95% for pancreatoduodenectomy, and 100% for Billroth II gastrectomy, hepaticojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y gastrojejunostomy, choledochojejunostomy, and Roux-en-Y pancreaticojejunostomy). The overall success rate of biliary or pancreatic duct cannulation was 90% (based on success rates of 91% for Roux-en-Y gastric bypass, 84% for pancreatoduodenectomy, and 100% for Billroth II gastrectomy, hepaticojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y gastrojejunostomy, choledochojejunostomy, and Roux-en-Y pancreaticojejunostomy). Similar to our study, DBE-assisted ERCP was successful in most of the cases in which reaching the blind end was successful and endoscopic therapeutic interventions could be carried out. Details of the treatment are equivalent to those of conventional ERCP cases. However, those reports are retrospective. To examine the efficacy and safety in the future, a prospective study with a large number of cases from multiple centers will be essential.

Comparison of DBE-assisted ERCP and SBE-assisted ERCP

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

Several endoscopists have suggested that there are a few disadvantages in carrying out small intestinal examination using the long-type DBE. The DBE has an additional balloon at the tip of the endoscope and this may be cumbersome. May et al.[49] reported that it took 15.4 min to prepare the DBE system. In contrast, Kawamura et al.[50] stated that they were able to prepare the SBE system within 5 min. With the DBE, the endoscopist must manage two balloon systems and it is possible to misjudge which balloon to inflate or deflate. This difficulty can cause procedural delays and does not occur with the SBE system. However, the ability to manage two balloon systems can be developed through experience. DBE is also disadvantageous in emergency situations, because of the preparation time required. However, Tsujikawa et al.[51] suggest that DBE is advantageous in cases with sharp angulations of the small intestine, because the balloon on the tip of the DBE can help pass around such angulations better than the hook shape of the SBE. We assume that not having a balloon on the tip of the SBE causes less advancing force during insertion. This is important because pancreatobiliary diseases in patients with altered gastrointestinal anatomy often deal with sharp angulations. Itoi et al.[52] reported an average time to reach the end of the Roux-en-Y limb of 35.5 min (10–86 min) using SBE, which is almost equivalent to the 40 min (5–120 min) reported by Aabakken et al.[38] using DBE. However, in our results, we found that the time to reach the blind end was nearly twice as long for ERCP using SBE compared to DBE (unpubl. obs, 2013). Although it may be difficult to compare the usefulness of SBE and long-type DBE, we suggest that DBE is more advantageous because it enables insertion to the blind end with more security and in a shorter time.

As the DBE was introduced before the development of the SBE, there were more reports of successful ERCP using DBE in patients with pancreaticobiliary diseases[30-48] compared with SBE.[52-57] Itoi et al.[52] and Dellon et al.[53] carried out diagnostic and therapeutic ERCP using an Olympus SBE. Itoi et al. described ERCP using SBE done in two patients with Billroth II anatomy and 11 patients with Roux-en-Y anatomy. The overall success rate of the therapeutic ERCP in the first session was 76.9% (10/13 patients). Dellon et al.[53] described four patients with Roux-en-Y anatomy: one with RYGB, two with Roux-en-Y anatomy caused by bile duct injury, and one with Roux-en-Y anatomy after liver transplantation. Cholangiography was successful in three of the four patients. Two patients required biliary dilation, which was successful in only one of the patients; the other patient required PTC because guidewire access to the common bile duct could not be established. Dellon et al. concluded that ERCP using SBE and DBE is feasible in patients with Roux-en-Y anastomosis. However, further studies on a larger number of cases will be necessary. Mönkemuller et al.[54] used the Fujinon DBE without placing a balloon on the tip of the endoscope as an SBE for diagnostic and therapeutic ERCP. Although they reported that intervention was possible, the stiffness of the scope and the position of the working channel of the scope are different, and it was too difficult to compare based on only the number of the balloons.

Comparison of Long-type and Short-type DBE-assisted ERCP

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

Most of the reports on DBE are regarding long-type DBE, and the success rate of ERCP varies from 60% to 100%. Because accessories for long-type DBE are not commercially available in Japan, the endoscope needs to be replaced during the procedure with a conventional forward-viewing upper endoscope,[55] which complicates the operation and results in a wide-ranging success rate.

For short-type DBE, Tsujino et al. reported an ERCP success rate of 100%, although they observed only a small number of cases.[35] Our ERCP success rate for a large number of cases was 95%. Siddiqui et al.[48] reported a success rate of 81%, which suggests the results of short-type DBE were satisfactory overall. We assume the reason for the higher success rate is that more devices are available for short-type DBE.

SE-assisted ERCP

SE is a new technique that uses a rotating overtube (Discovery SB [DSB] overtube; Spirus Medical, Inc., Stoughton, MA, USA) to pleat the small bowel onto the enteroscope, advancing it through the lumen. Recently, there have been several reports on SE-assisted ERCP.[58-62] These reports suggest that SE-assisted ERCP is as feasible as BAE-ERCP; however, in Japan this is not a commonly performed procedure at present.

Complications

The common complications for BAE-ERCP (bleeding, perforation, and post-ERCP pancreatitis) can also be caused by conventional ERCP. Although patients with bowel reconstruction who undergo ERCP have a higher incidence of complications than patients with normal gastrointestinal anatomy,[63, 64] the actual rates of morbidity associated with BAE-ERCP are unknown. The risk of retroperitoneal perforation in patients with a Billroth II surgery has been reported to be as high as 7–10%.[64] Although assessment of the complications for Roux-en Y reconstruction has not been established, there are some reports of perforation.[65, 66] It is essential to collect and analyze data of complications using large case studies, especially for Roux-en Y reconstruction.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References

The need for endoscopic therapeutic intervention for pancreatobiliary diseases with altered gastrointestinal anatomy is increasing, and the advent of BAE provides a new possibility for treatment. The procedure and the methods of BAE-ERCP are yet to be confirmed; however, improvement and development of the scopes and accessories as well as the establishment of techniques, adaptations, and contraindications are required to ensure further success and the safety of the procedure.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Surgically Altered Anatomy
  5. Endoscopes
  6. BAE Instruments
  7. Entering the Afferent Limb
  8. BAE-ERCP Technique
  9. Comparison of DBE-assisted ERCP and SBE-assisted ERCP
  10. Comparison of Long-type and Short-type DBE-assisted ERCP
  11. Conclusion
  12. Conflict of Interests
  13. References
  • 1
    Suisse A, Yassin K, Lavy A et al. Outcome and early complications of ERCP: A prospective single center study. Hepatogastroenterology 2005; 52: 352355.
  • 2
    Freeman ML, Guda NM. ERCP cannulation: A review of reported techniques. Gastrointest. Endosc. 2005; 61: 112125.
  • 3
    Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut 1984; 25: 971974.
  • 4
    Maaser C, Lenze F, Bokemeyer M et al. Double balloon enteroscopy: A useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system. Am. J. Gastroenterol. 2008; 103: 894900.
    Direct Link:
  • 5
    Teplick SK, Flick P, Brandon JC. Transhepatic cholangiography in patients with suspected biliary disease and nondilated intrahepatic bile ducts. Gastrointest. Radiol. 1991; 16: 193197.
  • 6
    Lin LF, Siauw CP, Ho KS et al. ERCP in post-Billroth II gastrectomy patients: Emphasis on technique. Am. J. Gastroenterol. 1999; 94: 144148.
    Direct Link:
  • 7
    Osnes M, Rosseland AR, Aabakken L. Endoscopic retrograde cholangiography and endoscopic papillotomy in patients with a previous Billroth-II resection. Gut 1986; 27: 11931198.
  • 8
    Hintze RE, Adler A, Veltzke W et al. Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with Billroth II or Roux-en-Y gastrojejunostomy. Endoscopy 1997; 29: 6973.
  • 9
    Wright BE, Cass OW, Freeman ML. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Gastrointest. Endosc. 2002; 56: 225232.
  • 10
    Chahal P, Baron TH, Topazian MD et al. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy 2006; 38: 12411245.
  • 11
    Elton E, Hanson BL, Qaseen T et al. Diagnostic and therapeutic ERCP using an enteroscope and pediatric colonoscope in long-limb surgical bypass patients. Gastrointest. Endosc. 1998; 47: 6267.
  • 12
    Gostout CJ, Bender CE. Cholangiopancreatography, sphincterotomy, and common duct stone removal via Roux-en-Y limb enteroscopy. Gastroenterology 1988; 95: 156163.
  • 13
    Kikuyama M, Sasada Y, Matsuhashi T et al. ERCP after Roux-en-Y reconstruction can be carried out using an oblique-viewing endoscope with an overtube. Dig. Endosc. 2009; 21: 180184.
  • 14
    Marsk R, Freedman J, Tynelius P et al. Antiobesity surgery in Sweden from 1980 to 2005: A population-based study with a focus on mortality. Ann. Surg. 2008; 248: 777781.
  • 15
    Flum DR, Salem L, Elrod JA et al. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005; 294: 19031908.
  • 16
    Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am. J. Surg. 2004; 188: 105110.
  • 17
    Smith FJ, Holman CD, Moorin RE et al. Incidence of bariatric surgery and postoperative outcomes: A population-based analysis in Western Australia. Med. J. Aust. 2008; 189: 198202.
  • 18
    Soejima Y, Taketomi A, Yoshizumi T et al. Biliary strictures in living donor liver transplantation: Incidence, management, and technical evolution. Liver Transpl. 2006; 12: 979986.
  • 19
    Yi NJ, Suh KS, Cho JY et al. In adult-to-adult living donor liver transplantation hepaticojejunostomy shows a better long-term outcome than duct-to-duct anastomosis. Transpl. Int. 2005; 18: 12401247.
  • 20
    Mercado MA, Chan C, Orozco H et al. Acute bile duct injury. The need for a high repair. Surg. Endosc. 2003; 17: 13511355.
  • 21
    Johnson SR, Koehler A, Pennington LK et al. Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery 2000; 128: 668677.
  • 22
    Yeo CJ, Cameron JL, Sohn TA et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: Pathology, complications, and outcomes. Ann. Surg. 1997; 226: 248257.
  • 23
    Meguid RA, Ahuja N, Chang DC. What constitutes a ‘high-volume’ hospital for pancreatic resection? J. Am. Coll. Surg. 2008; 206: 622, e1.
  • 24
    Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest. Endosc. 2001; 53: 216220.
  • 25
    Sunada K, Yamamoto H. Technology and indications. Gastrointest. Endosc. Clin. N. Am. 2009; 19: 325333.
  • 26
    Gerson LB. Capsule endoscopy and deep enteroscopy: Indications for the practicing clinician. Gastroenterology 2009; 137: 11971201.
  • 27
    Akerman PA, Cantero D. Spiral enteroscopy and push enteroscopy. Gastrointest. Endosc. Clin. N. Am. 2009; 19: 357369.
  • 28
    Yamauchi H, Kida M, Okuwaki K et al. Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy. World J. Gastroenterol. 2013; 19: 17281735.
  • 29
    Yano T, Hatanaka H, Yamamoto H et al. Intraluminal injection of indigo carmine facilitates identification of the afferent limb during double balloon ERCP. Endoscopy 2012; 44: E340E341.
  • 30
    Shimatani M, Matsushita M, Takaoka M et al. ‘Short’ double balloon enteroscope for endoscopic retrograde cholangiopancreatography with conventional sphincterotomy and metallic stent placement after Billroth II gastrectomy. Endoscopy 2009; 41: E1920.
  • 31
    Lin CH, Tang JH, Cheng CL et al. Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth II gastrectomy. World J. Gastroenterol. 2010; 16: 45944598.
  • 32
    Albrecht H, Konturek PC, Diebel H, Kraus F, Hahn EG, Raithel M. Successful interventional treatment of postoperative bile duct leakage after Billroth II resection by unusual procedure using double balloon enteroscopy. Med. Sci. Monit. 2011; 17: CS2933.
  • 33
    Haruta H, Yamamoto H, Mizuta K et al. A case of successful enteroscopic balloon dilation for late anastomotic stricture of choledochoduodenostomy after living donor liver transplantation. Liver Transpl. 2005; 11: 16081610.
  • 34
    Mehdizadeh S, Ross A, Gerson L et al. What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers. Gastrointest. Endosc. 2006; 64: 740750.
  • 35
    Tsujino T, Yamada A, Isayama H et al. Experiences of biliary interventions using short double-balloon enteroscopy in patients with Roux-en-Y anastomosis or hepaticojejunostomy. Dig. Endosc. 2010; 22: 211216.
  • 36
    Haber GB. Double balloon endoscopy for pancreatic and biliary access in altered anatomy (with videos). Gastrointest. Endosc. 2007; 66: S4750.
  • 37
    Emmett DS, Mallat DB. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: A case series. Gastrointest. Endosc. 2007; 66: 10381041.
  • 38
    Aabakken L, Bretthauer M, Line PD. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy 2007; 39: 10681071.
  • 39
    Mönkemüller K, Bellutti M, Neumann H et al. Therapeutic ERCP with the double-balloon enteroscope in patients with Roux-en-Y anastomosis. Gastrointest. Endosc. 2008; 67: 992996.
  • 40
    Masser C, Lenze F, Bokemeyer M et al. Double balloon enteroscopy: A useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system. Am. J. Gastroenterol. 2008; 103: 894900.
    Direct Link:
  • 41
    Chu YC, Yang CC, Yeh YH et al. Double-balloon enteroscopy application in biliary tract disease-its therapeutic and diagnostic functions. Gastrointest. Endosc. 2008; 68: 585591.
  • 42
    Koornstra JJ, Fry L, Mönkemüller K et al. ERCP with the balloon-assisted enteroscopy technique: A systematic review. Dig. Dis. 2008; 26: 324329.
  • 43
    Matsushita M, Shimatani M, Takaoka M et al. ‘Short’ double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy. Am. J. Gastroenterol. 2008; 103: 32183219.
    Direct Link:
  • 44
    Matsushita M, Shimatani M, Takaoka M et al. Effective endoscope for endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis: A single-, double-, or ‘short’ double-balloon enteroscope? Dig. Dis. Sci. 2010; 28: 871875.
  • 45
    Matsushita M, Shimatani M, Ikeura T et al. ‘Short’ double-balloon or single-balloon enteroscope for ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis. Am. J. Gastroenterol. 2010; 105: 2294.
  • 46
    Shimatani M, Matsushita M, Takaoka M et al. Effective ‘short’ double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: A large case series. Endoscopy 2009; 41: 849854.
  • 47
    Shah RJ, Smolkin M, Yen R, Ross A et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest. Endosc. 2013; 77: 593600.
  • 48
    Siddiqui AA, Chaaya A, Shelton C et al. Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study. Dig. Dis. Sci. 2013; 58: 858864.
  • 49
    May A, Nachbar L, Ell C. Double-balloon enteroscopy (push-and pull enteroscopy) of the small bowel: Feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease. Gastrointest. Endosc. 2005; 62: 6270.
  • 50
    Kawamura T, Yasuda K, Tanaka K et al. Clinical evaluation of a newly developed single-balloon enteroscope. Gastrointest. Endosc. 2008; 68: 11121116.
  • 51
    Tsujikawa T, Saitoh Y, Andoh A et al. Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: Preliminary experiences. Endoscopy 2008; 40: 1115.
  • 52
    Itoi T, Ishii K, Sofuni A et al. Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video). Am. J. Gastroenterol. 2010; 105: 9399.
  • 53
    Dellon ES, Kohn GP, Morgan DR et al. Endoscopic retrograde cholangiopancreatography with single-balloon enteroscopy is feasible in patients with a prior Roux-en-Y anastomosis. Dig. Dis. Sci. 2009; 54: 17981803.
  • 54
    Mönkemuller K, Fry LC, Bellutti M et al. ERCP using single-balloon instead of double-balloon enteroscopy in patients with Roux-en-Y anastomosis. Endoscopy 2008; 40: E1920.
  • 55
    Neumann H, Fry LC, Meyer F et al. Endoscopic retrograde cholangiopancreatography using the single balloon enteroscope technique in patients with Roux-en-Y anastomosis. Digestion 2009; 80: 5257.
  • 56
    Moreels TG, Pelckmans PA. Comparison between double-balloon and single-balloon enteroscopy in therapeutic ERC after Roux-en-Y entero-enteric anastomosis. World J. Gastrointest. Endosc. 2010; 2: 314317.
  • 57
    Wang AY, Sauer BG, Behm BW et al. Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy. Gastrointest. Endosc. 2010; 71: 641649.
  • 58
    Chandrasekhara V, Lennon AM, Singh V et al. ERCP using spiral enteroscopy in patients with altered gastrointestinal anatomy. Am. J. Gastroenterol. 2009; 104 (Suppl 3): S384.
  • 59
    Shah RJ. Spiral enteroscopy-assisted ERCP in patients with long limb surgical biliary bypass. Endoscopy 2009; 41 (Suppl 1): A25.
  • 60
    Shah RJ, Smolkin M, Ross AS et al. A multi-center, U.S. experience of single balloon, double balloon, and rotational overtube enteroscopy-assisted ERCP in long limb surgical bypass patients. Gastrointest. Endosc. 2010; 71: AB134135.
  • 61
    Kogure H, Watabe H, Yamada A et al. Spiral enteroscopy for therapeutic ERCP in patients with surgically altered anatomy: Actual technique and review of the literature. J. Hepatobiliary Pancreat. Sci. 2011; 18: 375379.
  • 62
    Lennon AM, Kapoor S, Khashab M et al. Spiral assisted ERCP is equivalent to single balloon assisted ERCP in patients with Roux-en-Y anatomy. Dig. Dis. Sci. 2012; 57: 13911398.
  • 63
    Bagci S, Tuzun A, Ates Y et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography in patients with Billroth II anastomosis. Hepatogastroenterology 2005; 52: 356359.
  • 64
    Faylona JM, Qadir A, Chan AC, Lau JY, Chung SC. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy 1999; 31: 546549.
  • 65
    Mönkemuller K, Fry LC, Bellutti M et al. ERCP with the double balloon enteroscope in patients with Roux-en-Y anastomosis. Surg. Endosc. 2009; 23: 19611967.
  • 66
    Itoi T, Ishii K, Sofuni A et al. Long- and short-type double balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis. Surg. Endosc. 2011; 25: 713721.