Case study
Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with surgically altered anatomy

Presented in part at the annual meeting of the American Society of Gastrointestinal Endoscopy, Digestive Diseases Week, May 30-June 4, 2009, Chicago, Illinois (Gastrointest Endosc 2009;69:AB152-3).
https://doi.org/10.1016/j.gie.2009.10.051Get rights and content

Background

In patients with surgically altered anatomy, ERCP is often unsuccessful. Single-balloon enteroscopy (SBE) enables deep intubation of the small bowel, permitting diagnostic and therapeutic ERCP in this subset of patients.

Objective

To determine the effectiveness of SBE in performing endoscopic retrograde cholangiography (ERC) in patients with surgically altered anatomy.

Design

Case series.

Setting

Large quaternary-care center.

Patients

Thirteen patients (11 women) underwent 16 SBE procedures with ERCP. Patient anatomy consisted of Whipple (n = 3), hepaticojejunostomy (n = 3), Billroth II (n = 1), and Roux-en-Y (n = 9).

Interventions

Patients with surgically altered anatomy in whom standard ERCP techniques had failed or were not possible underwent ERC by using SBE with initial therapeutic intent.

Main Outcome Measurements

Success rates of diagnostic ERC and therapeutic ERC in those patients who required biliary intervention. Procedure-related complications were also assessed.

Results

Diagnostic ERC was successful 12 (92.3%) of 13 patients and in 13 (81.3%) of 16 cases. Therapeutic ERC was required in 10 patients in whom diagnostic ERC was first accomplished, and therapeutic ERC was successful in 9 (90%) of 10 patients. Biliary interventions included balloon dilation (n = 4), stone extraction (n = 2), sphincterotomy (n = 4), removal of a surgically placed stent (n = 3), and stenting (n = 2). Two patients developed pancreatitis after therapeutic ERC. Median follow-up was 53 days (range 22-522 days). Overall procedural success in an intent-to-treat analysis by case was 75%.

Limitation

Single-center experience.

Conclusion

SBE enables diagnostic and therapeutic ERC in most patients with altered anatomy. SBE-assisted therapeutic ERC may be associated with an increased risk of pancreatitis. Improvement of the available equipment is necessary to perform more efficient and effective biliary interventions.

Section snippets

Methods

Patients with surgically altered gastroduodenal anatomy with a diagnosis requiring therapeutic ERC were offered SBE. SBE was performed by using a high-resolution standard-length enteroscope, with a 9.2-mm diameter and a 200-cm length (SIF-Q180; Olympus America, Center Valley, PA). A disposable sliding overtube, with a 13.2-mm outer diameter, an 11-mm inner diameter, a 130.2-cm length, and a hydrophilic coating over a silicone core (ST-SB1; Olympus America), was used to sequentially reduce and

Patient characteristics

Thirteen patients (2 men, 11 women) with a median age of 54 years (range 28-82 years) underwent 16 SBE procedures (cases), from October 2007 to April 2009, with the intent to perform therapeutic ERC (Table 1).

Surgically altered anatomy in the 16 procedures performed consisted of pancreaticoduodenectomy with HJ (Whipple, n = 3), HJ alone (n = 3), Billroth II with a long afferent limb (n = 1), Roux-en-Y anatomy after partial gastrectomy for ulcer disease (n = 1), and RYGB (n = 8). In 3 of the 16

Discussion

Historically, Billroth II gastrectomy was the predominant form of surgically altered anatomy that fostered challenging ERCP procedures. During the late 1990s and early 2000s, multiple studies reported excellent ERCP success by using duodenoscopes or enteroscopes in patients with Billroth II anatomy,19, 20, 21 likely because of shorter afferent limbs. However, the incidence of Billroth II surgeries has decreased because of more effective treatment for peptic ulcer disease.

Today, the surgically

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    DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: V. M. Shami: Consultant for Olympus. M. Kahaleh: Grant support fromOlympus, Boston Scientific, Alveolus, ConMed, Cook Medical. All other authors disclosed no financial relationships relevant to this publication.

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