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Ding S, Dong S, Zhu H, Hu Y, Zheng S, Li Q. Use of short single-balloon enteroscopy in patients with surgically altered anatomy: a single-center experience. Sci Rep 2024; 14:27889. [PMID: 39537967 PMCID: PMC11560932 DOI: 10.1038/s41598-024-79633-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 11/11/2024] [Indexed: 11/16/2024] Open
Abstract
Conventional duodenoscopy is challenging to perform in patients with a surgically altered anatomy (SAA). Short single-balloon enteroscopy (SBE) is an innovative alternative. We investigated the performance of short SBE in patients with SAA and explored risk factors for unsuccessful intubation. Patients who underwent short SBE from October 2019 to October 2023 were retrospectively analyzed. Successful enteroscopic intubation was defined as the endoscope reaching the papilla of Vater, the pancreaticobiliary-enteric anastomosis, or the target site of the afferent limb. In total, 99 short SBE procedures were performed in 64 patients (40 men, 24 women) with a mean age of 61 years (range, 36-86 years). The patients had a history of choledochoduodenostomy (n = 1), Billroth II gastrojejunostomy (n = 11), pancreaticoduodenectomy (n = 17), Roux-en-Y reconstruction with hepaticojejunostomy (n = 31), and Roux-en-Y reconstruction with total gastrectomy (n = 4). Successful enteroscopic intubation occurred in 32 of 64 (50.0%) patients, and in 57 of 99 (57.6%) procedures. No perforation or severe pancreatitis occurred. Multivariable analysis showed that Roux-en-Y reconstruction was a risk factor for intubation failure (hazard ratio, 4.2; 95% confidence interval, 1.1-15.8; p = 0.033). Short SBE is efficacious and safe in patients with postsurgical anatomy. Roux-en-Y reconstruction adversely affects the success of short SBE intubation.
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Affiliation(s)
- Songming Ding
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, #848 Dongxin Road, Hangzhou, Zhejiang, P.R. China
| | - Shanjie Dong
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, #848 Dongxin Road, Hangzhou, Zhejiang, P.R. China
| | - Hengkai Zhu
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, #848 Dongxin Road, Hangzhou, Zhejiang, P.R. China
| | - Yiting Hu
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, #848 Dongxin Road, Hangzhou, Zhejiang, P.R. China
| | - Shusen Zheng
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, #848 Dongxin Road, Hangzhou, Zhejiang, P.R. China
| | - Qiyong Li
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, #848 Dongxin Road, Hangzhou, Zhejiang, P.R. China.
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, #848 DongXin Road, Hangzhou, 310003, China.
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Caillol F, Godat S, Solovyev A, Harouchi A, Oumrani S, Marx M, Hoibian S, Dahel Y, Ratone JP, Giovannini M. EUS-BD for calibration of benign stenosis of the bile duct in patients with altered anatomy or inaccessible papilla. Endosc Int Open 2024; 12:E377-E384. [PMID: 38464978 PMCID: PMC10919993 DOI: 10.1055/a-2261-2968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/01/2024] [Indexed: 03/12/2024] Open
Abstract
Background and study aims In cases of inaccessible papilla, EUS-guided biliary drainage (EUS-BD) has been described as an alternative to calibrate benign biliary stenosis. However, few studies are available. Patients and methods This tw-center, retrospective study was designed to evaluate technical success and clinical success at 1 year. All patients who underswent EUS-BD without the rendezvous technique used for calibration of benign biliary stenosis were included from 2016 to 2022. Patients underwent EUS-hepaticogastrostomy (EUS-HGS) during the first session. Then, HGS was used to access the bile duct, allowing calibration of the stenosis: Dilation of the biliary stenosis and placement of double pigtail stents through the stenosis for 1 year. Results Thirty-six patients were included. Technical success was 89% (32/36), with four failures to cross the stenosis but EUS-HGS was performed in 100% of the cases. Nine patients were excluded during calibration because of oncological relapse in six and complex stenosis in three. Three patients had not yet reached 1 year of follow-up. Twenty patients had a calibration for at least 1 year. Clinical success after stent placement was considered in all cases after 1 year of follow-up. Thirteen patients underwent stent removal and no relapse occurred after 435 days of follow-up (SD=568). Global morbidity was 41.7% (15/36) with only one serious complication (needing intensive care), including seven cases of cholangitis due to intrabiliary duct obstruction and five stent migrations. No deaths were reported. Conclusions EUS-BD for calibration in case of benign biliary stenosis is an option. Dedicated materials are needed to decrease morbidity.
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Affiliation(s)
- Fabrice Caillol
- Endoscopy Unit, Paoli-Calmettes Institute, Marseille, France
| | - Sébastien Godat
- gastroentérologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Alexey Solovyev
- Statistics Unit, Paoli-Calmettes Institute, Marseille, France
| | - Amina Harouchi
- Endoscopy Unit, Paoli-Calmettes Institute, Marseille, France
| | - Sarra Oumrani
- Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland
| | - Mariola Marx
- Endoscopy Unit, Paoli-Calmettes Institute, Marseille, France
| | - Solene Hoibian
- Endoscopy Unit, Paoli-Calmettes Institute, Marseille, France
| | - Yanis Dahel
- Endoscopy Unit, Paoli-Calmettes Institute, Marseille, France
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Yamamoto H, Despott EJ, González-Suárez B, Pennazio M, Mönkemüller K. The evolving role of device-assisted enteroscopy: The state of the art as of August 2023. Best Pract Res Clin Gastroenterol 2023; 64-65:101858. [PMID: 37652651 DOI: 10.1016/j.bpg.2023.101858] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Device-assisted enteroscopy (DAE), balloon-assisted enteroscopy (BAE) in particular, has become a routine endoscopic procedure which has revolutionized our approach to small-bowel disease. Evidence demonstrating the efficacy and safety of BAE spans over 22-years of experience, making it an established pillar of minimally invasive care. The robust evidence for BAE's safety and efficacy has now been incorporated into international clinical guidelines, technical reviews, benchmarking performance measures and curricula. The more recently introduced motorized spiral enteroscopy (MSE) which had replaced the previous manual version, abruptly ended its 7-year stint in clinical practice, when it was withdrawn and recalled from the market by its manufacturing company in July 2023, due to several associated serious adverse events (including fatalities). This article, written by the original developer of double-balloon enteroscopy (DBE) and other recognized international experts and pioneers in this field, focuses mainly on the technical aspects, evolving indications, and equipment-related technological advances. Despite the very recent withdrawal of MSE from clinical practice, for completeness, this technology and its technique is still briefly covered here, albeit importantly, along with a short description of reported, associated, serious adverse events which have contributed to its withdrawal/recall from the market and clinical practice.
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Affiliation(s)
- Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Tochigi, Japan.
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, London, UK
| | - Begoña González-Suárez
- Department of Gastroenterology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Marco Pennazio
- University Division of Gastroenterology, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Klaus Mönkemüller
- Division of Gastroenterology "Prof. Carolina Olano", Universidad de La República, Montevideo, Uruguay; Division of Endoscopy, Ameos Teaching University Hospital, Halberstadt, Germany; Department of Gastroenterology, Virginia Tech Carilion School of Medicine, Virginia, USA
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Gkolfakis P, Papaefthymiou A, Facciorusso A, Tziatzios G, Ramai D, Dritsas S, Florou T, Papanikolaou IS, Hassan C, Repici A, Triantafyllou K, Aabakken L, Devière J, Beyna T, Arvanitakis M. Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:1646. [PMID: 36295081 PMCID: PMC9605390 DOI: 10.3390/life12101646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP. METHODS A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs). RESULTS Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3-89.4); I2: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4-99.4; I2: 0%) and 99.1% (95%CI: 98.6-99.7; I2: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3-78.0; I2: 86.9%) and 69.1% (95%CI: 65.3-72.9; I2: 91.8%) after EA-ERCP, 98% (95%CI: 96.5-99.6; I2: 0%) and 97.9% (95%CI: 96.3-99.4) after EDGE, and 98.6% (95%CI: 97.9-99.2; I2: 0%) and 98.5% (95%CI: 97.8-99.2; I2: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40-20.8); I2: 87.1%], and EDGE [13.1% (95%CI: 7.50-18.8); I2: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50-6.80); p ≤ 0.04; I2: 64.2%]. CONCLUSIONS LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
| | | | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, 124 62 Chaidari, Greece
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Spyridon Dritsas
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil BA21 4AT, UK
| | - Theodosia Florou
- Department of Gastroenterology, University Hospital of Larissa, 411 10 Larissa, Greece
| | - Ioannis S. Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, 124 62 Chaidari, Greece
| | - Cesare Hassan
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Alessandro Repici
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, “Attikon” University General Hospital, 124 62 Chaidari, Greece
| | - Lars Aabakken
- GI Endoscopy Unit, Institute of Clinical Medicine, Oslo University Hospital, 0372 Oslo, Norway
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
| | - Torsten Beyna
- Department of Internal Medicine, Evagelisches Krankenhaus Düsseldorf, 40225 Düsseldorf, Germany
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
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Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques. Medicina (B Aires) 2022; 58:medicina58010120. [PMID: 35056428 PMCID: PMC8779004 DOI: 10.3390/medicina58010120] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/14/2022] Open
Abstract
Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.
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Gerges C, Vázquez AG, Tringali A, Verde JM, Dertmann T, Houghton E, Cina A, Beyna T, Begnis FS, Pizzicannella M, Palermo M, Perretta S, Costamagna G, Marescaux J, Neuhaus H, Boškoski I, Giménez ME. Percutaneous transhepatic cholangioscopy using a single-operator cholangioscope (pSOC), a retrospective, observational, multicenter study. Surg Endosc 2021; 35:6724-6730. [PMID: 33398561 DOI: 10.1007/s00464-020-08176-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Percutaneous cholangioscopy (PC) is more complex and invasive than a transpapillary approach, with the need for a large percutaneous tract of 16 French (Fr) on average in order to advance standard percutaneous cholangioscopes. The aim of this study was to investigate whether percutaneous single-operator cholangioscopy (pSOC) using the SpyGlass™ DS system is feasible, safe, and effective in PC for diagnostic and therapeutic indications. MATERIALS AND METHODS The data of 28 patients who underwent pSOC in 4 tertiary referral centers were retrospectively analyzed. Technical and clinical success for therapeutic procedures was assessed as well as diagnostic accuracy of pSOC-guided biopsies and visualization. Adverse events and the required number and size of dilatations were reviewed. RESULTS 25/28 (89%) patients had a post-surgical altered anatomy. The average number of percutaneous dilatations prior to pSOC was 1.25 with a mean dilatation size of 11 French. Histopathology showed a 100% accuracy. Visual impression showed an overall accuracy of 96.4%. Technical and clinical success was achieved in 27/28 (96%) of cases. Adverse events occurred in 3/28 (10.7%) cases. CONCLUSION pSOC is a feasible, safe, and effective technique for diagnostic and therapeutic indications. It may be considered an alternative approach in clinical cases where gastrointestinal anatomy is altered. It has the potential to reduce peri-procedural adverse events and costs. Prospective randomized-controlled trials are necessary to confirm the previously collected data.
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Affiliation(s)
| | - Alain García Vázquez
- Institute of Image-Guided Surgery, 1 place de l´Hopital, 67091, Strasbourg, France
- Research Institute against Digestive Cancer, IRCAD, Strasbourg University, Strasbourg, France
| | - Andrea Tringali
- Digestive Endoscopy Unit, Center for Endoscopic Research Therapeutics and Training (CERTT), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- Radiology Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Juan Manuel Verde
- Institute of Image-Guided Surgery, 1 place de l´Hopital, 67091, Strasbourg, France.
- Research Institute against Digestive Cancer, IRCAD, Strasbourg University, Strasbourg, France.
| | | | - Eduardo Houghton
- Daicim Foundation, Training, Research, and Clinical activity in Minimally Invasive Surgery, Buenos Aires, Argentina
| | - Alessandro Cina
- Radiology Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Federico Sylvestre Begnis
- Daicim Foundation, Training, Research, and Clinical activity in Minimally Invasive Surgery, Buenos Aires, Argentina
| | - Margherita Pizzicannella
- Institute of Image-Guided Surgery, 1 place de l´Hopital, 67091, Strasbourg, France
- Research Institute against Digestive Cancer, IRCAD, Strasbourg University, Strasbourg, France
| | - Mariano Palermo
- Daicim Foundation, Training, Research, and Clinical activity in Minimally Invasive Surgery, Buenos Aires, Argentina
| | - Silvana Perretta
- Institute of Image-Guided Surgery, 1 place de l´Hopital, 67091, Strasbourg, France
- Research Institute against Digestive Cancer, IRCAD, Strasbourg University, Strasbourg, France
| | - Guido Costamagna
- Digestive Endoscopy Unit, Center for Endoscopic Research Therapeutics and Training (CERTT), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- Radiology Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jacques Marescaux
- Research Institute against Digestive Cancer, IRCAD, Strasbourg University, Strasbourg, France
| | | | - Ivo Boškoski
- Digestive Endoscopy Unit, Center for Endoscopic Research Therapeutics and Training (CERTT), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- Radiology Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mariano Eduardo Giménez
- Institute of Image-Guided Surgery, 1 place de l´Hopital, 67091, Strasbourg, France
- Research Institute against Digestive Cancer, IRCAD, Strasbourg University, Strasbourg, France
- Daicim Foundation, Training, Research, and Clinical activity in Minimally Invasive Surgery, Buenos Aires, Argentina
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Cheng KS, Li MKK, Yip WM, Choi WL, Fong MC. Endoscopic retrograde cholangiopancreatography using short-type double-balloon enteroscope: Experience in Hong Kong. J Dig Dis 2021; 22:545-550. [PMID: 34390529 DOI: 10.1111/1751-2980.13040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To illustrate the efficacy and safety profile of double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) using a short enteroscope in patients with surgically altered anatomy. METHODS A retrospective study was performed to review the endoscopic outcomes of patients undergoing DBE-assisted ERCP for biliary diseases in Tuen Mun and Pok Oi hospitals in Hong Kong SAR, China from December 2015 to December 2020. RESULTS Altogether 46 DBE-assisted ERCP procedures were performed in 37 patients. The enteroscopic success rate, defined as reaching the papilla or bilioenteric anastomosis, was 95.7% (95% confidence interval [CI] 85.2%-99.5%), which was significantly lower in patients with intact stomach than in those who had a previous gastrectomy (67% vs 100%, P = 0.014). The diagnostic ERCP success rate, defined as performance in an informative cholangiogram, was 84.1% (95% CI 69.9%-93.4%) in cases where it was attempted. Intended biliary therapeutic interventions were successfully performed in 76.1% (95% CI 61.2%-87.4%) of all procedures. Adverse events were reported in six (13.0%) procedures (95% CI 4.9%-26.3%), including the micro-perforation of the intestine in two (4.3%) patients with prior Roux-en-Y gastrectomy, three (6.5%) of acute cholangitis and one (2.2%) of acute pancreatitis. All adverse events were managed successfully using conservative methods except in one case of micro-perforation, which required a laparotomy. CONCLUSIONS DBE-assisted ERCP using a short enteroscope is a promising technique for managing biliary diseases in patients with surgically altered anatomy. It must be performed to avoid perforation, particularly in patients with a Roux-en-Y reconstruction.
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Affiliation(s)
- Ka Shing Cheng
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR, China
| | - Michael Kin Kong Li
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR, China
| | - Wai Man Yip
- Department of Medicine and Geriatrics, Pok Oi Hospital, Au Tau, Hong Kong SAR, China
| | - Wai Lok Choi
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR, China
| | - Man Chung Fong
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR, China
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8
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Nennstiel S, Freivogel K, Faber A, Schlag C, Haller B, Blöchinger M, Dollhopf M, Lewerenz B, Schepp W, Schirra J, Schmid RM, Neu B. Endoscopic and percutaneous biliary interventions in patients with altered upper gastrointestinal anatomy-the Munich Multicenter Experience. Surg Endosc 2021; 35:6853-6864. [PMID: 33398586 DOI: 10.1007/s00464-020-08191-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/17/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era. PATIENTS AND METHODS Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed. RESULTS At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease. CONCLUSION In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.
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Affiliation(s)
- Simon Nennstiel
- Medizinische Klinik und Poliklinik Für Innere Medizin II, Klinikum Rechts der Isar der TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Kathrin Freivogel
- Innere Medizin I, Krankenhaus Barmherzige Brüder München, Romanstraße 93, 80639, Munich, Germany
| | - Alexander Faber
- Medizinische Klinik und Poliklinik Für Innere Medizin II, Klinikum Rechts der Isar der TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Schlag
- Medizinische Klinik und Poliklinik Für Innere Medizin II, Klinikum Rechts der Isar der TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- Institut für Medizinische Informatik, Statistik und Epidemiologie, Klinikum Rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, Munich, Germany
| | - Martin Blöchinger
- Klinik für Gastroenterologie und Hepatologie, München Klinik Neuperlach (München Klinik gGmbH), Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany
| | - Markus Dollhopf
- Klinik für Gastroenterologie und Hepatologie, München Klinik Neuperlach (München Klinik gGmbH), Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany
| | - Björn Lewerenz
- Klinik für Gastroenterologie, Hepatologie und Gastroenterologische Onkologie, München Klinik Bogenhausen (München Klinik gGmbH), Englschalkinger Straße 77, 81925, Munich, Germany
| | - Wolfgang Schepp
- Klinik für Gastroenterologie, Hepatologie und Gastroenterologische Onkologie, München Klinik Bogenhausen (München Klinik gGmbH), Englschalkinger Straße 77, 81925, Munich, Germany
| | - Jörg Schirra
- Medizinische Klinik und Poliklinik 2, Klinikum der Universität München Standort Großhadern, Marchioninistraße 15, 81377, Munich, Germany
| | - Roland M Schmid
- Medizinische Klinik und Poliklinik Für Innere Medizin II, Klinikum Rechts der Isar der TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bruno Neu
- Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Akademisches Lehrkrankenhaus der TU München, Achdorferweg 3, 84036, Landshut, Germany
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Hakuta R, Kogure H, Nakai Y, Hamada T, Sato T, Suzuki Y, Inokuma A, Kanai S, Nakamura T, Noguchi K, Ishigaki K, Saito K, Saito T, Takahara N, Mizuno S, Yamada A, Tada M, Koike K. Feasibility of balloon endoscope-assisted endoscopic retrograde cholangiopancreatography for the elderly. Endosc Int Open 2020; 8:E1202-E1211. [PMID: 32904855 PMCID: PMC7458759 DOI: 10.1055/a-1216-1363] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) for patients with surgically altered anatomy is challenging. Recently, balloon endoscopy has been shown to facilitate ERCP for this population with a high technical success rate, but adverse events (AEs) are not uncommon. Compared to non-elderly patients, elderly patients may be at higher risk of AEs due to underlying comorbidities. The current study aimed to evaluate the feasibility of balloon endoscope-assisted ERCP (BE-ERCP) for the elderly. Patients and methods We retrospectively identified patients who underwent BE-ERCP between January 2010 and September 2019. For patients who underwent multiple procedures during the study period, the first session was analyzed. Early AEs associated with BE-ERCP were compared between elderly (≥ 75 years) and non-elderly patients. Results A total of 1,363 BE-ERCP procedures were performed, and 568 patients (211 elderly and 357 non-elderly) were included for the analyses. Technical success rates were high in both the elderly and non-elderly groups (80 % vs. 80 %, respectively). The rates of early AEs were similar between the groups (12 % vs. 9.0 % in the elderly and non-elderly group, respectively; P = 0.31). The mltivariable-adjusted odds ratio for early AEs comparing elderly to non-elderly patients was 1.36 (95 % confidence interval, 0.74-2.51; P = 0.32). Specifically, we did not observe between-group differences in rates of gastrointestinal perforation (2.4 % vs. 2.8 % in elderly and non-elderly groups, respectively; P = 0.99) and aspiration pneumonia (1.9 % vs. 0.6 %, P = 0.20). Conclusions BE-ERCP is a feasible procedure for elderly individuals with surgically altered anatomy.
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Affiliation(s)
- Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukari Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akiyuki Inokuma
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoka Nakamura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensaku Noguchi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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10
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Tokuhara M, Shimatani M, Mitsuyama T, Masuda M, Ito T, Miyamoto S, Fukata N, Miyoshi H, Ikeura T, Takaoka M, Kouda K, Okazaki K. Evaluation of complications after endoscopic retrograde cholangiopancreatography using a short type double balloon endoscope in patients with altered gastrointestinal anatomy: a single-center retrospective study of 1,576 procedures. J Gastroenterol Hepatol 2020; 35:1387-1396. [PMID: 32103516 DOI: 10.1111/jgh.15019] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) using balloon-assisted endoscope such as double-balloon endoscope is even effective for patients with surgically altered anatomy. Yet comprehensive studies on complications of ERCP using balloon-assisted endoscope have not been made. We analyzed the characteristics and the causes of complications of ERCP using double-balloon endoscope (DB-ERCP) procedures and aimed to suggest effective managements. METHODS A total of 1576 procedures of DB-ERCP in 714 patients with surgically altered gastrointestinal anatomy in our hospital were evaluated retrospectively using a statistic analysis. RESULTS The overall complication occurrence rate was 5.8%. By type of complications are perforation 3.2%, mucosal laceration 0.5%, hemorrhage 1.0%, pancreatitis 0.6%, respiratory disorder 0.4%, and others 0.2%. By type of surgical reconstruction methods were Roux-en-Y reconstruction with choledocho-jejunal anastomosis 4.2%, Roux-en-Y reconstruction without choledocho-jejunal anastomosis 6.7%, pancreaticoduodenectomy 4.5%, pylorus preserving pancreaticoduodenectomy 4.2%, Billroth II gastrectomy (B-II) 11.6%, and other reconstruction method (others) 7.4%. The contributing factors calculated by a multivariate analysis were B-II (odds ratio: 1.864, 95% confidence interval: 1.001-3.471, P = 0.050) and the presence of naïve papilla (odds ratio: 3.268, 95% confidence interval: 1.426-7.490, P = 0.005). CONCLUSIONS DB-ERCP is a safe method with a total complication rate of 5.8% that could be considered within an acceptable range. The most common complication was the injury of the digestive tract such as perforation. Affecting risk factors for complications were B-II and the presence of naïve papilla. DB-ERCP procedures should be performed carefully of these factors.
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Affiliation(s)
- Mitsuo Tokuhara
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Masaaki Shimatani
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Toshiyuki Mitsuyama
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Masataka Masuda
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Takashi Ito
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Sachi Miyamoto
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Norimasa Fukata
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Hideaki Miyoshi
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Makoto Takaoka
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Katsuyasu Kouda
- Department of Hygiene and Public Health, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Kazuichi Okazaki
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
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Sirin G, Hulagu S. Double balloon enteroscopy improves ERCP success in patients with modified small bowel anatomy. North Clin Istanb 2020; 7:131-139. [PMID: 32259034 PMCID: PMC7117630 DOI: 10.14744/nci.2020.54533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/21/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of double-balloon enteroscopy (DBE) on the success of endoscopic retrograde cholangiopancreatography (ERCP) procedures in patients with surgically modified gastrointestinal (GI) tract anatomy. METHODS The medical records of patients who underwent ERCP in the Gastroenterology Department of Kocaeli University School of Medicine hospital between December 2008 and September 2014 were examined. From the patient group that was scheduled to undergo DBE-ERCP, the details of cases in which ERCP via standard duodenoscope or DBE-ERCP was performed during the same session because standard ERCP failed were included. Procedure parameters, outcomes, and complications related to the procedure in both groups were analyzed. Patients who underwent the DBE-ERCP procedure directly, those who underwent push enteroscopy, or gastroscopy to evaluate the GI tract anatomy before the day of ERCP, and who underwent DBE-ERCP on a day other than the initial ERCP session were excluded. Afferent loop intubation, access to the major papilla, selective cannulation, therapeutic success rates, and the effect of DBE on overall procedure success were evaluated. RESULTS Fifty-one patients with a history of BII gastrojejunostomy and 11 patients with hepaticojejunostomy (with or without Roux-en-Y) were included in the study. In all patients, the ERCP procedure was initiated with a standard duodenoscope. If intubation of the afferent loop was unsuccessful in reaching the major papilla or enterobiliary anastomosis, DBE was used. In 30 (48.4%) of the 62 patients whose GI tract was anatomically altered, the duodenoscope was successfully advanced to the ampulla and 27 (43.5%) were cannulated successfully. Thirty-one patients underwent DBE-ERCP. DBE reached the ampulla or enterobiliary anastomosis in 30 patients (96.8%) and selective choledocus cannulation was achieved in all patients but 3 (90%), including 1 patient with a hepaticojejunostomy. The overall ERCP success rate increased from 43.5% (27/62) to 87.1% (54/62). Two perforations (1 during standard duodenoscopy and 1 with DBE-ERCP) were observed. CONCLUSION The overall success rate of ERCP increased with use of the DBE technique in patients with small bowel anatomic variations that were the result of previous surgery.
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Affiliation(s)
- Goktug Sirin
- Department of Gastroenterology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Sadettin Hulagu
- Department of Gastroenterology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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12
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Pizzicannella M, Caillol F, Pesenti C, Bories E, Ratone JP, Giovannini M. EUS-guided biliary drainage for the management of benign biliary strictures in patients with altered anatomy: A single-center experience. Endosc Ultrasound 2020; 9:45-52. [PMID: 31552913 PMCID: PMC7038727 DOI: 10.4103/eus.eus_55_19] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Objectives: The management of benign biliary stricture in patients with altered anatomy secondary to surgery is challenging. Percutaneous transhepatic biliary drainage (BD) represents the standard therapy for benign biliary stricture, but it is associated with nontrivial morbidity rates. Despite the increasing application of guided BD (EUS-BD) for the management of malignant obstruction, its role in patients with benign biliary stricture is limited. This retrospective study aimed to evaluate the feasibility, safety, and clinical effectiveness of EUS-BD with multiple transanastomotic plastic stent treatment in patients with benign biliary stricture. Materials and Methods: This study included consecutive patients who underwent EUS-BD for benign biliary stenosis at our center. EUS-BD with fully covered self-expandable metal stent placement was performed first. When feasible, the stricture was treated by balloon dilation with the placement of a transanastomotic double-pigtail plastic stent. Scheduled procedures were repeated to remove the metal stent and replace the plastic stent to treat the stenosis. Technical success and adverse events (AEs) were assessed. Results: Twelve patients underwent EUS-BD for benign biliary strictures. Procedural and clinical successes were achieved in all patients (100%). Multistenting treatment was performed in 10/12 patients (77%). The median number of stents inserted, maximum number of stents placed, and median time of retreatment were 2.4 (range: 1–4), 4, and 3.4 (range: 1–7), respectively. In total, 4/12 patients (33.3%) developed AEs that required endoscopic interventions (Clavien-Dindo Grade III). Conclusions: EUS-BD with the placement of multiple trans-stenosis plastic stents is a safe, feasible, and well-tolerated alternative for the management of benign biliary stricture in patients with surgery-altered anatomy. Long-term follow-up is necessary to support our results.
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Affiliation(s)
| | - Fabrice Caillol
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Erwan Bories
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Marc Giovannini
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
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13
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Yamada A, Kogure H, Nakai Y, Takahara N, Mizuno S, Tada M, Koike K. Performance of a new short-type double-balloon endoscope with advanced force transmission and adaptive bending for pancreaticobiliary intervention in patients with surgically altered anatomy: A propensity-matched analysis. Dig Endosc 2019; 31:86-93. [PMID: 30151924 DOI: 10.1111/den.13261] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM A new short-type double-balloon endoscope (DBE) has been developed with a major focus on facilitating scope insertion to the target site for pancreaticobiliary interventions in patients with surgically altered anatomy. We investigated the performance of this new short-type DBE by comparing it with a conventional DBE. METHODS Data from 885 endoscopic retrograde cholangiopancreatography (ERCP) procedures using balloon endoscopy were analyzed. We used propensity score matching to adjust for differences between patients who underwent ERCP procedures using the new short-type DBE versus the conventional short-type DBE. RESULTS A total of 163 pairs of patients were selected by propensity score matching. Success rate of reaching the target site was 100% in both the new DBE group and the conventional DBE group (P = 1.0). The new DBE group had a shorter insertion time required to reach the target site than the conventional DBE group (10 min vs. 14 min, P < 0.01). Success rate of pancreaticobiliary interventions in the new DBE group was as high as that in the conventional DBE group (92% vs. 89% P = 0.35). Overall procedure time decreased from 62 min in the conventional DBE group to 55 min in the new DBE group (P = 0.26). No significant differences in the rates of adverse events were observed between the two groups. CONCLUSION A new short-type DBE allows faster insertion to the target site for pancreaticobiliary intervention in patients with surgically altered anatomy.
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Affiliation(s)
- Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Shao XD, Qi XS, Guo XZ. Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: A meta-analysis. Saudi J Gastroenterol 2017; 23:150-160. [PMID: 28611338 PMCID: PMC5470374 DOI: 10.4103/1319-3767.207713] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to evaluate the effectiveness and safety of endoscopic retrograde cholangiopancreatography with double balloon enteroscope (DBE-ERCP) in patients with altered gastrointestinal anatomy in a meta-analysis. MATERIALS AND METHODS A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane library covering the period from January 2001 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using the I2 test. RESULTS Ten studies involving a total of 301 patients were included in the analysis. The pooled enteroscopy, diagnostic, and therapeutic success rates were 89.75% [95% confidence interval (CI): 79.65-94.30%], 79.92% (95% CI: 68.06-89.59%), and 63.55% (95% CI: 53.70-72.86%), respectively. DBE-ERCP-related complications occurred in 18 patients including perforation (5), pancreatitis (3), cholangitis (9), and bleeding (1). The incidence of DBE-ERCP-related complication was 6.27% (95% CI: 2.61-11.38%). CONCLUSION Diagnostic and therapeutic DBE-ERCPs are feasible in patients with altered gastrointestinal anatomy. DBE-ERCP may be considered when pancreaticobiliary diseases occur in patients undergoing Roux-en-Y reconstruction or pancreaticoduodenectomy.
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Affiliation(s)
- Xiao-Dong Shao
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China
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15
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Souto-Rodríguez R, Alvarez-Sánchez MV. Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results. World J Gastrointest Endosc 2017; 9:105-126. [PMID: 28360973 PMCID: PMC5355758 DOI: 10.4253/wjge.v9.i3.105] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/12/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.
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Liu K, Joshi V, Saxena P, Kaffes AJ. Predictors of success for double balloon-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis. Dig Endosc 2017; 29:190-197. [PMID: 27637997 DOI: 10.1111/den.12739] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/14/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) in patients with roux-en-Y anastomosis (REYA) is challenging. Use of double balloon enteroscope-assisted ERCP (DBE-ERCP) has been successful. We aim to determine predictors of successful biliary cannulation with DBE-ERCP in patients with REYA. METHODS We retrospectively studied patients with REYA who had DBE-ERCP between 2009 and 2015. RESULTS 86 DBE-ERCP were done on 52 patients. Patients had REYA for liver transplant (n = 26), gastrojejunostomy (n = 9), previous bile duct injury (n = 9), biliary atresia (n = 2) and other (n = 6). The biliary-enteric anastomosis was reached in 76% and cholangiogram was successful in 70%. Highest success rates were in patients with previous bile duct injury (94%) or gastrojejunostomy (89%). Post-transplant patients had intermediate success (64%). Patients with redo surgery (46%) and childhood surgery (38%), especially Kasai procedure (20%), had low success. Patients with previous bile duct injury were more likely to succeed (94% vs 63%, P = 0.010). Those more likely to fail were patients with childhood surgery (38% vs 73%, P = 0.037), biliary atresia (20% vs 73%, P = 0.013) and second operation post-transplant (25% vs 70%, P = 0.046). CONCLUSION Indication for REYA impacts on successful biliary cannulation in patients undergoing DBE-ERCP. The procedure is most successful in non-liver transplant adult surgery and post-transplant patients without a second operation. It is least successful in patients with surgically corrected biliary atresia and post-transplant patients with second operation. Alternative methods of biliary access should be considered in these patients.
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Affiliation(s)
- Ken Liu
- Faculty of Medicine, University of Sydney, Sydney, Australia.,AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Vikram Joshi
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Arthur J Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
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17
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Shimatani M, Hatanaka H, Kogure H, Tsutsumi K, Kawashima H, Hanada K, Matsuda T, Fujita T, Takaoka M, Yano T, Yamada A, Kato H, Okazaki K, Yamamoto H, Ishikawa H, Sugano K. Diagnostic and Therapeutic Endoscopic Retrograde Cholangiography Using a Short-Type Double-Balloon Endoscope in Patients With Altered Gastrointestinal Anatomy: A Multicenter Prospective Study in Japan. Am J Gastroenterol 2016; 111:1750-1758. [PMID: 27670601 DOI: 10.1038/ajg.2016.420] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the utility and safety of a short-type double-balloon endoscope (DBE) in the treatment of biliary disease in patients with surgically altered gastrointestinal (GI) anatomy. METHODS This study was conducted as a multicenter, single-arm, prospective trial at five tertiary academic care centers and three community-based hospitals in Japan. Consecutive patients with biliary disease with altered GI anatomy were prospectively included in this study. RESULTS A total of 311 patients underwent double-balloon endoscopic retrograde cholangiography (ERC). The success rate of reaching the target site, the primary end point, was 97.7% (95% confidence interval (CI): 95.4-99.1). The success rate of biliary cannulation and contrast injection of the targeted duct, the secondary end point, was 96.4% (95% CI: 93.6-98.2), and the therapeutic success rate was 97.9% (95% CI: 95.4-99.2). Adverse events occurred in 33 patients (10.6%, 95% CI: 7.1-14.0) and were managed conservatively in all patients with the exception of 1 in whom a perforation developed, requiring emergency surgery. CONCLUSIONS ERC using a short-type DBE resulted in an excellent therapeutic success rate and a low rate of adverse events. This treatment can be a first-line treatment for biliary disease in patients with surgically altered GI anatomy.
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Affiliation(s)
- Masaaki Shimatani
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Hisashi Hatanaka
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koichiro Tsutsumi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Hiroshima, Japan
| | - Tomoki Matsuda
- Digestive Endoscopy Center, Sendai Kousei Hospital, Sendai, Japan
| | - Tomoki Fujita
- Center for Gastroenterology, Otaru Ekisaikai Hospital, Hokkaido, Japan
| | - Makoto Takaoka
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Tomonori Yano
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazuichi Okazaki
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Hideki Ishikawa
- Department of Molecular-Targeting Cancer Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kentaro Sugano
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
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Double-balloon Enteroscopy for Pediatric Patients: Evaluation of Safety and Efficacy in 257 Cases. J Pediatr Gastroenterol Nutr 2016; 63:34-40. [PMID: 26628449 DOI: 10.1097/mpg.0000000000001048] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The safety and efficacy of double-balloon enteroscopy (DBE) in pediatric patients has not been well documented. We aimed to evaluate the clinical efficacy and safety of DBE in children, especially those under 10. METHODS We retrospectively analyzed our database of DBE procedures performed between September 2000 and September 2013. Procedures performed in pediatric patients (under 18) were selected from a total of 3980, including double-balloon endoscopic retrograde cholangioscopy (DBERC). RESULTS Two hundred fifty-seven DBE procedures were performed in 117 pediatric patients (median age 12.5 years). Antegrade (oral-route) DBE was performed in 166 procedures including 104 DBERC procedures (lowest body weight 13.5 kg, youngest age 3 years), and retrograde (anal-route) DBE in 91 (lowest body weight 12.0 kg, youngest age 2 years). The overall diagnostic yield for obscure gastrointestinal bleeding and abdominal pain was 58.8%. The purpose of DBERC was achieved in 76.9% of procedures. The overall complication rate in our series was 5.4% (1.9% with the DBERC cases removed); in patients under 10, it was 10.4% (7/67). No severe complications associated with enteroscope insertion and sedation were observed. Serum amylase levels tended to be elevated in patients who underwent oral-route DBE. CONCLUSIONS DBE is safe and feasible for diagnostic evaluation of small bowel disorders in pediatric patients, even those younger than 10 years. Special attention for possible complications must, however, be paid during therapeutic DBE procedures, including DBERC, especially for patients under 10.
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Enestvedt BK, Kothari S, Pannala R, Yang J, Fujii-Lau LL, Hwang JH, Konda V, Manfredi M, Maple JT, Murad FM, Woods KL, Banerjee S. Devices and techniques for ERCP in the surgically altered GI tract. Gastrointest Endosc 2016; 83:1061-75. [PMID: 27103361 DOI: 10.1016/j.gie.2016.03.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/04/2016] [Indexed: 02/08/2023]
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Sharzehi K. Biliary strictures in the liver transplant patient. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Use of the Conventional Side-viewing Duodenoscope for Successful Endoscopic Retrograde Cholangiopancreatography in Postgastrectomy Patients. J Clin Gastroenterol 2016; 50:244-51. [PMID: 26535481 PMCID: PMC4741407 DOI: 10.1097/mcg.0000000000000442] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the usefulness of the conventional side-viewing duodenoscope for successful endoscopic retrograde cholangiopancreatography (ERCP) in postgastrectomy patients. METHODS A total of 220 consecutive patients with bile duct stones or a distal common bile duct stricture who had previously undergone gastrectomy and were referred for ERCP were analyzed for the outcome of their ERCP. All ERCP procedures were performed using a conventional side-viewing duodenoscope. In patients who had undergone a Billroth II gastroenterostomy and total gastrectomy with Roux-en-Y reconstruction, we also used the procedure of retrieval balloon-assisted enterography. RESULTS The study group included 220 patients who had previously undergone gastrectomy (77 women and 143 men; mean age, 72.2 y; range, 11 to 93 y). The overall enterography success rate was 90.5% (199/220), and the diagnostic and ERCP success rates were both 88.6% (195/220). Endoscopy was unsuccessful in 21 patients who received Billroth II gastroenterostomy and Roux-en-Y reconstruction. After successful endoscopy, diagnostic and ERCP success was not achieved in 4 patients with Billroth II gastroenterostomy, with or without Braun anastomosis, due to cannulation failure. The procedure-related complication rate was 5.5% (12/220), including immediate bleeding (0.9%, 2/220), pancreatitis (4.1%, 9/220), and perforation (0.5%, 1/220). There were no procedure-related deaths. CONCLUSIONS The side-viewing duodenoscope is a useful instrument for performing successful ERCP in patients postgastrectomy. In addition, retrieval balloon-assisted enterography may improve the enterography success rate in postgastrectomy patients with Billroth II and Roux-en-Y reconstruction.
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Recurrent cholangitis by biliary stasis due to non-obstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy: report of a case. Int Surg 2015; 99:426-31. [PMID: 25058778 PMCID: PMC4114374 DOI: 10.9738/intsurg-d-13-00243.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.
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Soh JS, Yang DH, Lee SS, Lee S, Bae J, Byeon JS, Myung SJ, Yang SK. Single Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients Who Underwent a Gastrectomy with Roux-en-Y Anastomosis: Six Cases from a Single Center. Clin Endosc 2015; 48:452-7. [PMID: 26473133 PMCID: PMC4604288 DOI: 10.5946/ce.2015.48.5.452] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/22/2014] [Accepted: 12/16/2014] [Indexed: 12/29/2022] Open
Abstract
Patients with altered anatomy such as a Roux-en-Y anastomosis often present with various pancreaticobiliary problems requiring therapeutic intervention. However, a conventional endoscopic approach to the papilla is very difficult owing to the long afferent limb and acute angle of a Roux-en-Y anastomosis. Balloon-assisted enteroscopy can be used for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered anatomy. We experienced six cases of Roux-en-Y anastomosis with biliary problems, and attempted ERCP using single balloon enteroscopy (SBE). SBE insertion followed by replacement with a conventional endoscope was attempted in five of six patients. The papilla was successfully approached using SBE in all cases. However, therapeutic intervention was completed in only three cases because of poor maneuverability caused by postoperative adhesion. We conclude that in patients with Roux-en-Y anastomosis, the ampulla can be readily accessed with SBE, but longer dedicated accessories are necessary to improve this therapeutic intervention.
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Affiliation(s)
- Jae Seung Soh
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seohyun Lee
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jungho Bae
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Araki A, Tsuchiya K, Watanabe M. Advances in balloon endoscopes. Clin J Gastroenterol 2015; 7:189-99. [PMID: 26183736 DOI: 10.1007/s12328-014-0485-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/25/2014] [Indexed: 01/10/2023]
Abstract
In September 2003, a double-balloon endoscope (DBE) composed of balloons attached to a scope and an overtube was released in Japan prior to becoming available in other parts of the world. The DBE was developed by Dr. Yamamoto (1), and 5 different types of scopes with different uses have already been marketed. In April 2007, a single-balloon small intestinal endoscope was released with a balloon attached only to the overtube as a subsequent model. This article presents a detailed account of the development of these scopes up to the present time.
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Affiliation(s)
- Akihiro Araki
- Department of Gastroenterology and Hepatology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan,
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Shimatani M, Takaoka M, Tokuhara M, Miyoshi H, Ikeura T, Okazaki K. Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy. World J Gastrointest Endosc 2015; 7:617-627. [PMID: 26078830 PMCID: PMC4461936 DOI: 10.4253/wjge.v7.i6.617] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 01/14/2015] [Accepted: 03/09/2015] [Indexed: 02/05/2023] Open
Abstract
The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.
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Nakahara K, Okuse C, Suetani K, Morita R, Michikawa Y, Ozawa SI, Hosoya K, Nomoto M, Kobayashi S, Otsubo T, Itoh F. Endoscopic retrograde cholangiography using an anterior oblique-viewing endoscope in patients with altered gastrointestinal anatomy. Dig Dis Sci 2015; 60:944-50. [PMID: 25326113 PMCID: PMC4408371 DOI: 10.1007/s10620-014-3386-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 10/03/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is technically more challenging in patients who have undergone gastrointestinal (GI) reconstruction. AIMS The aim of this study was to evaluate the utility of the anterior oblique-viewing endoscope (AOE) for ERCP in patients with a retained major duodenal papilla after GI reconstruction. METHODS This was a retrospective study involving 40 patients (50 procedures) with a retained papilla after GI reconstruction who underwent ERCP using AOE. Reconstruction consisted of Billroth II gastrectomy (BII) in 25 patients (30 procedures) and Roux-en-Y anastomosis (RY) in 15 patients (20 procedures). In RY cases, the long single-balloon enteroscope (LSBE) was exchanged with AOE after reaching the papilla. RESULTS The overall rate of reaching the papilla using AOE was 90.0 % (45/50) [BII; 86.7 % (26/30), RY; 95.0 % (19/20)]. The overall rate of biliary cannulation was 97.8 % (44/45) [BII; 100 % (26/26), RY; 94.7 % (18/19)], and the rate of biliary cannulation for intact papilla was 96.6 % (28/29) [BII; 100 % (14/14), RY; 93.3 % (14/15)]. Treatment success rate in cases of successful biliary cannulation was 97.7 % (43/44) [BII; 100 % (26/26), RY; 94.4 % (17/18)]. The rate of adverse events was 6.0 % (3/50) [BII; 3.3 % (1/30), RY; 10.0 % (2/20)], with mild pancreatitis occurring in 3 cases. CONCLUSIONS High biliary cannulation and treatment rates can be achieved during ERCP using AOE in altered GI anatomy cases with a retained papilla, as long as the papilla can be reached. In RY cases, exchanging AOE with LSBE is useful after reaching the papilla.
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Affiliation(s)
- Kazunari Nakahara
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Chiaki Okuse
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Keigo Suetani
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Ryo Morita
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Yosuke Michikawa
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Shun-ichiro Ozawa
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Kosuke Hosoya
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Masahito Nomoto
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Shinjiro Kobayashi
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Takehito Otsubo
- Department of Gastroenterological and General Surgery, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
| | - Fumio Itoh
- Department of Gastroenterology and Hepatology, School of Medicine, St. Marianna University, 2-16-1, Sugao, Miyamae-ku, Kawasaki, 216-8511 Japan
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Skinner M, Velázquez-Aviña J, Mönkemüller K. Using balloon-overtube-assisted enteroscopy for postoperative endoscopic retrograde cholangiopancreatography. Therap Adv Gastroenterol 2014; 7:269-79. [PMID: 25364385 PMCID: PMC4212471 DOI: 10.1177/1756283x14544154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is technically more challenging in patients with postsurgical anatomy such as Roux-en-Y anastomosis, frequently mandating an operative intervention. Although limited, there is growing evidence that ERCP can be performed using the balloon-overtube-assisted enteroscopy (BOAE) in patients with complex postoperative anatomy. We present the technical aspects of performing ERCP with the BOAE in patients presenting with complex postsurgical anatomy having biliary problems. ERCP using the BOAE is feasible in patients with complex postsurgical anatomy, permitting diagnostic and therapeutic interventions in 80% of patients.
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Affiliation(s)
- Matthew Skinner
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, AL, USA
| | - Jacobo Velázquez-Aviña
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, AL, USA
| | - Klaus Mönkemüller
- Division of Gastroenterology and Hepatology, Basil Hirschowitz Endoscopic Center of Excellence, Endoscopy Unit, JT 664, 619 19th Street S, Birmingham, AL 35249, USA
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Surgical revision of hepaticojejunostomy strictures after pancreatectomy. Langenbecks Arch Surg 2014; 400:67-75. [PMID: 25277247 DOI: 10.1007/s00423-014-1246-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 08/21/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND After pancreatic surgery hepaticojejunostomy (HJ) stricture is a rare condition. Usually, management is conservative, while operative revision ("redo") is only rarely performed. METHODS This was an observational cohort design that analyzed the outcome of patients who had a surgical revision of HJ strictures after pancreatic surgery at a specialized pancreatic center. RESULTS During a period of 7 years from January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy (PD) or HJ. Among this patient population, 3 % (23/887) underwent a redo of the HJ secondary to stricture formation. Major symptoms of HJ strictures were recurrent cholangitis in 91 % (21/23) and jaundice in 39 % (9/23). The median time from the index operation until redo of the HJ was 16 ± 27 months. The median survival of patients with malignancy after redo of the HJ was 45 ± 67 months. Major surgical morbidity was 9 % (2/23), and mortality was 0 % (0/23). In 78 % (18/23), there were no further episodes of cholangitis after a median follow of 49 ± 73 months, while none of the patients with redo of the HJ developed a restenosis of the HJ. CONCLUSION Surgical revision (redo) of HJ strictures can be safely performed by an experienced pancreatic surgeon with a low morbidity without mortality with good long-term results.
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29
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Skinner M, Peter S, Wilcox CM, Mönkemüller K. Diagnostic and therapeutic utility of double-balloon enteroscopy for obscure GI bleeding in patients with surgically altered upper GI anatomy. Gastrointest Endosc 2014; 80:181-186. [PMID: 24785130 DOI: 10.1016/j.gie.2014.02.1034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 02/27/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Matthew Skinner
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, Alabama, USA
| | - Shajan Peter
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, Alabama, USA
| | - C Mel Wilcox
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, Alabama, USA
| | - Klaus Mönkemüller
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, Alabama, USA
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Kato H, Tsutsumi K, Harada R, Okada H, Yamamoto K. Short double-balloon enteroscopy is feasible and effective for endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 2:130-5. [PMID: 24750163 DOI: 10.1111/den.12251] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/12/2014] [Indexed: 12/14/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) for patients with digestive tract reconstruction is a difficult procedure from an anatomical point of view. A short-type double-balloon enteroscope has a 2.8-mm working channel and a 152-cm working length, and its advantage is that it can accommodate most conventional devices for ERCP. Although the shorter length compared with the long-type balloon-assisted enteroscope (BAE) was suspected of making it difficult or impossible to reach the blind end, in fact, the success rate of reaching the blind end with the short type is similar to that with the long- type BAE. In addition, the success rate of ERCP-related procedures with the short type is satisfactory. However, it remains controversial as to which BAE is more suitable for this procedure. Further randomized controlled trials by high-volume centers are warranted.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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DuCoin C, Moon RC, Teixeira AF, Jawad MA. Laparoscopic choledochoduodenostomy as an alternate treatment for common bile duct stones after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2014; 10:647-52. [PMID: 24913592 DOI: 10.1016/j.soard.2014.01.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/31/2013] [Accepted: 01/06/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), the new gastrointestinal configuration does not permit easy endoscopic access to the biliary system in the standard fashion. Common bile duct (CBD) stones have proved to be a challenge for both the surgeon and the endoscopist in this setting. We shall review our experience with laparoscopic choledochoduodenostomy as a treatment of choledocholithiasis after gastric bypass. METHODS Between January 2000 and July 2012, 3115 patients underwent RYGB at our institution. Patients were included if they had postoperative CBD stones regardless of previous cholecystectomy. Treatment modality was laparoscopic choledochoduodenostomy. A retrospective chart review of a prospectively collected data was completed, noting the outcomes and complications of the procedure. RESULTS Of 3115 patients, 11 patients were included in this study. There were 8 female and 3 male patients with a mean age of 50.5 ± 10.9 (range, 34-66) years. The average time between primary RYGB and choledochoduodenostomy was 39.7 ± 33.8 (range 8-113) months. The average body mass index at primary surgery was 48.2 ± 8.1 (range 38.4-67.4) kg/m(2) and at choledochoduodenostomy was 29.5 ± 6.8 (range 22.7-46.9) kg/m(2). One patient had bile leak that was managed with drain. All patients had resolution of symptoms at a mean follow-up of 24.8 ± 26.9 (range 2-84) months. CONCLUSION This small case series suggests that, in experienced hands, laparoscopic choledochoduodenostomy is an option for safe and effective treatment of choledocholithiasis after gastric bypass.
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Affiliation(s)
- Christopher DuCoin
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida
| | - Rena C Moon
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida
| | - Andre F Teixeira
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida
| | - Muhammad A Jawad
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, Orlando, Florida.
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Shimatani M, Takaoka M, Matsushita M, Okazaki K. Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 1:70-8. [PMID: 24118126 DOI: 10.1111/den.12175] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/16/2013] [Indexed: 12/11/2022]
Abstract
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 and to 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.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
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Kianička B, Lata J, Novotný I, Dítě P, Vaníček J. Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejunoanastomosis. World J Gastroenterol 2013; 19:8047-8055. [PMID: 24307799 PMCID: PMC3848153 DOI: 10.3748/wjg.v19.i44.8047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 08/22/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepaticojejunoanastomosis (HJA).
METHODS: The study took place from January 2009 to December 2011 and we retrospectively assessed 15 patients with Roux-en-Y HJA who had signs of biliary obstruction. In total, 23 ERC procedures were performed in these patients and a single balloon videoenteroscope (Olympus SIF Q 180) was used in all of the cases. A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope. Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of ≤ 5.4 kPa. The technical limitations or rather the parameters of the single balloon enteroscope (working length - 200 cm, diameter of the working channel - 2.8 mm, absence of Albarran bridge) showed the need for special endoscopic instrumentation.
RESULTS: Cannulation success was reached in diagnostic ERC in 12 of 15 patients. ERC findings were normal in 1 of 12 patients. ERC in the remaining 11 patients showed some pathological changes. One of these (cystic bile duct dilation) was subsequently resolved surgically. Endoscopic treatment was initialized in the remaining 10 patients (5 with HJA stenosis, 2 with choledocholithiasis, and 3 with both). This treatment was successful in 9 of 10 patients. The endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis - 11 times (7 patients); choledocholitiasis extraction - five times (5 patients); biliary plastic stent placement - six times (4 patients); and removal of biliary stents placed by us - six times (4 patients). The mean time of performing a single ERC was 72 min. The longest procedure took 110 min and the shortest took 34 min. This shows that it is necessary to allow for more time in individual procedures. Furthermore, these procedures require the presence of an anesthesiologist. We did not observe any complications in these 15 patients.
CONCLUSION: This method is more demanding than standard endoscopic retrograde cholangiopancreatography due to altered postsurgical anatomy. However, it is effective, safe, and widens the possibilities of resolving biliary pathology.
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Pancreaticojejuno-jejunostomy during reconstruction of the afferent loop in surgery of radiation-induced afferent loop obstruction following pancreaticoduodenectomy with Roux-en-Y reconstruction. Updates Surg 2013; 66:51-7. [PMID: 24254381 DOI: 10.1007/s13304-013-0238-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 11/11/2013] [Indexed: 12/19/2022]
Abstract
Radiation-induced afferent loop obstruction is a rare complication following pancreaticoduodenectomy and adjuvant radiotherapy. As in the setting of Roux-en-Y reconstruction endoscopic approaches are limited, surgery of this complication becomes inevitable. This study provides a new classification/management system of the radiation-induced obstruction of the afferent loop based on the extent and location of radiation injury, and describes the Pancreaticojejuno-jejunostomy, a novel technique to avoid revision of the pancreatic anastomosis during reconstruction of the afferent loop. Data were analyzed from nine patients who developed radiation-induced afferent loop obstruction after pancreaticoduodenectomy with single Roux limb reconstruction. One patient had type I obstruction and treated with by-pass surgery, seven patients had type II obstruction and treated with reconstruction including revision of the hepaticojejunostomy and Pancreaticojejuno-jejunostomy, and one patient had type III obstruction and treated with reconstruction including revision of the hepaticojejunostomy and the pancreatic anastomosis. Reconstruction along with Pancreaticojejuno-jejunostomy performed in six patients with type II radiation-induced afferent loop obstruction; reconstruction was not feasible for one patient. The median operative time was 149 min. No intraoperative complication was observed. By performing Pancreaticojejuno-jejunostomy we managed efficiently to convert a pancreatic anastomosis to an enteric anastomosis as one case of Grade B pancreatic fistula and no case of Pancreaticojejuno-jejunostomy stricture were observed, regarding short- and long-term results, respectively. The above technique may have a useful application in the surgical management of the radiation-induced afferent loop obstruction when endoscopy fails and by-pass surgery is inappropriate.
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Ikeura T, Shimatani M, Takaoka M, Matsushita M, Miyoshi H, Kurishima A, Sumimoto K, Miyamoto S, Okazaki K. Intrahepatic cholangiocarcinoma diagnosed via endoscopic retrograde cholangiopancreatography with a short double-balloon enteroscope. World J Gastroenterol 2013; 19:4427-4431. [PMID: 23885158 PMCID: PMC3718915 DOI: 10.3748/wjg.v19.i27.4427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 02/20/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) using a double-balloon enteroscope (DBE) in patients with bowel reconstruction due to a previous abdominal surgery is now widely accepted. In particular, a short DBE, which has a 2.8-mm working channel and 152-cm working length, is useful for ERCP because of its good rotational and straightening ability and the availability of various conventional ERCP accessories through the working channel. Herein we report a case of intrahepatic cholangiocarcinoma via ERCP with a short DBE. This is the first report in which the pre-cutting and the brush cytological examination were performed successfully under a DBE to diagnose intrahepatic cholangiocarcinoma pathologically. The short DBE allowed us to perform all diagnostic and therapeutic procedures accepted in conventional ERCP in patients with surgically altered anatomies.
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Does single-balloon enteroscopy contribute to successful endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy? ISRN GASTROENTEROLOGY 2013; 2013:214958. [PMID: 23762573 PMCID: PMC3671229 DOI: 10.1155/2013/214958] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/28/2013] [Indexed: 12/22/2022]
Abstract
Background. Balloon-assisted enteroscopy has been recognized as a useful method for performing endoscopic retrograde cholangiopancreatography in patients with complex postsurgical anatomy. Objective. To clarify the usefulness of single-balloon enteroscopy for performing endoscopic retrograde cholangiopancreatography successfully in patients after Billroth II gastrectomy or Roux-en-Y reconstruction and compare it with that of conventional endoscopy. Patients and Methods. We analyzed 204 endoscopic retrograde cholangiopancreatography procedures performed at Kyoto Second Red Cross Hospital between 1997 and 2011 in 93 patients after Billroth II gastrectomy and Roux-en-Y reconstruction with gastrectomy and choledochojejunostomy. We compared recent results with those achieved before the advent of single-balloon enteroscopy (“pre-single-balloon enteroscopy” group versus “post-single-balloon enteroscopy” group). Results. The rate of reaching the blind end was 11/12 (91.7%) in post-single-balloon enteroscopy Roux-en-Y gastrectomy cases and 3/9 (33.3%) in pre-single-balloon enteroscopy Roux-en-Y gastrectomy cases (P = 0.015). The rate of accomplishing target procedures was 7/12 (58.3%) in post-single-balloon enteroscopy Roux-en-Y gastrectomy cases. No significant difference was found in the rates for Billroth II gastrectomy cases. Conclusion. The single-balloon enteroscopy system is effective in reaching the blind end in patients who have undergone Roux-en-Y reconstruction; however, further innovations are needed to accomplish endoscopic retrograde cholangiopancreatography-related procedures.
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Kucukay F, Okten RS, Yurdakul M, Ozdemir E, Erat S, Parlak E, Disibeyaz S, Ozer I, Bostanci EB, Olcer T, Tola M. Long-term results of percutaneous biliary balloon dilation treatment for benign hepaticojejunostomy strictures: are repeated balloon dilations necessary? J Vasc Interv Radiol 2013; 23:1347-55; quiz 1357. [PMID: 22999755 DOI: 10.1016/j.jvir.2012.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 06/27/2012] [Accepted: 07/03/2012] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To determine the safety, efficacy, and long-term results of percutaneous biliary balloon dilation (PBBD) of benign hepaticojejunostomy strictures and evaluate the necessity of repeated PBBD in this setting. MATERIALS AND METHODS PBBD was performed after traversing hepaticojejunostomy strictures in 89 patients (40 male, 49 female; age range, 19-84 y; mean age ± SD, 54.5 y ± 14.0), who were divided into three groups: group I (one satisfactory initial PBBD; n = 41), group II (two or more PBBDs with satisfactory initial PBBD; n = 33), and group III (two or more PBBDs without satisfactory PBBD; n = 15). Groups I and II were randomized. The primary outcome measure was the absence of clinical biliary obstruction symptoms at 24 months. Secondary outcome measures included technical and clinical success, primary and secondary patency, major complications, and mortality. Categoric variables were compared between groups I and II. RESULTS Procedure-related mortality and major morbidity rates were 0% and 5.6%, respectively. Mean primary and secondary patency durations were 45.3 months ± 2.2 and 71.3 months ± 15.4, respectively. The follow-up period was 36.4 months ± 15.1. The primary outcome measure was achieved in 73% of patients. Technical and clinical success rates (secondary outcome measures) were 97.8% and 84.3%, respectively. Repeated PBBD procedures were not satisfactory in 16.9% of patients. No significant differences in categoric variables were observed between groups I and II. CONCLUSIONS PBBD of benign hepaticojejunostomy strictures is a safe and effective procedure. Repeated PBBD is not required when the first procedure is successful.
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Affiliation(s)
- Fahrettin Kucukay
- Department of Radiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey.
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Lee A, Shah JN. Endoscopic approach to the bile duct in the patient with surgically altered anatomy. Gastrointest Endosc Clin N Am 2013; 23:483-504. [PMID: 23540972 DOI: 10.1016/j.giec.2012.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy can be technically challenging, because of three main problems that must be overcome: (1) endoscopically traversing the altered luminal anatomy, (2) cannulating the biliary orifice from an altered position, and (3) performing biliary interventions with available ERCP instruments. This article addresses the most common and most challenging variations in anatomy encountered by a gastroenterologist performing ERCP. It also highlights the innovations and progress that have been made in coping with these anatomic variations, with special attention paid to altered anatomy from bariatric surgery.
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Affiliation(s)
- Alexander Lee
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA 94143, USA
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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; 58:858-64. [PMID: 22975796 DOI: 10.1007/s10620-012-2385-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 08/23/2012] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography (DBE-ERCP) is an effective method for interventions in the pancreaticobiliary system in the post-surgical patient. However, use of currently available endoscopic accessories during this procedure is limited due of the length of the conventional instrument (200 cm). The aim of this study was to explore the utility of the short DBE (152 cm) for the management of pancreaticobiliary disorders in patients with surgically altered anatomies. METHODS Data were collected retrospectively on patients with various anatomic variations in whom ERCP was performed using the short DBE from April 2008 to November 2011. Basic demographic information, clinical presentation, preoperative imaging, and type of surgery, procedural technical success rate, and adverse events were evaluated. Descriptive analysis was used to document the demographic and clinical data of the patients. RESULTS We identified 79 patients in whom DBE-ERCP was attempted (38 % male, mean age 58 years). Indications for the procedure were removal of a previously placed stent (n = 5), suspected sphincter of Oddi dysfunction type 1 (n = 3), surgical biliary leak (n = 3), pancreatic anastomotic stricture (n = 2), suspected biliary stones (n = 48), and biliary strictures visualized on imaging (n = 18). Overall, the success rate of DBE-ERCP in all patients was 81 % (64/79). The scope could not reach the papilla or surgical anastomosis in 8 cases and duct cannulation failed in 7 cases. The following interventions were performed: biliary sphincterotomy (n = 39), dilation of CBD stenosis with a balloon (n = 30), biliary stent insertion (n = 25), stone removal (n = 35), brushing cytology of biliary strictures (n = 3), and stent retrieval (n = 4). Three patients developed post-procedure pancreatitis. There was 1 episode of self-limited bleeding. CONCLUSIONS The current study demonstrates that DBE assisted ERCP for pancreaticobiliary interventions using a short enteroscope are feasible in patients with surgically altered anatomy.
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Zhuang M, Zhang W, Gu J, Gong W, Wang X. ERCP with retrieval balloon-assisted enterography using traditional duodenoscope in post-GI surgery patients. Gastrointest Endosc 2013; 77:315-6. [PMID: 23317697 DOI: 10.1016/j.gie.2012.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 09/20/2012] [Indexed: 02/08/2023]
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Zhuang M, Zhang WJ, Gu J, Liu YB, Wang XF. Retrieval-balloon-assisted enterography in post-pancreaticoduodenectomy endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2012; 18:7109-7112. [PMID: 23323016 PMCID: PMC3531702 DOI: 10.3748/wjg.v18.i47.7109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 09/28/2012] [Indexed: 02/06/2023] Open
Abstract
This case reports an application of conventional duodenoscope in a post pancreaticoduodenectomy patient with the help of retrieval balloon assisted enterography. The 56-year-old woman had pancreaticoduodenectomy with Child reconstruction 9 mo ago because of pancreatic adenocarcinoma and now there are recurrent enlarged lymph nodes in the anastomotic stoma of hepaticojejunostomy. Considering the patient’s late-stage cancer, a plastic stent was then successfully placed there to drainage. The main challenge in this case was the extremely long afferent loop and blind cannulation through the anastomotic stoma of hepaticojejunostomy. Retrieval balloon assisted enterography is very helpful for duodenoscope going through the reconstructed intestinal tract and for the cannulation. After two weeks, the patient remained free of painful symptoms and free of fever. Liver function improved well. Four months after the placement of stent, the patient died of cachexia without jaundice, fever and abdominal pain according to her daughter’s statement.
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Osoegawa T, Motomura Y, Akahoshi K, Higuchi N, Tanaka Y, Hisano T, Itaba S, Gibo J, Yamada M, Kubokawa M, Sumida Y, Akiho H, Ihara E, Nakamura K. Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2012; 18:6843-9. [PMID: 23239923 PMCID: PMC3520174 DOI: 10.3748/wjg.v18.i46.6843] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/27/2012] [Accepted: 10/16/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy.
METHODS: Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO2 insufflations.
RESULTS: The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis.
CONCLUSION: Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.
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Tsutsumi K, Kato H, Tomoda T, Matsumoto K, Sakakihara I, Yamamoto N, Noma Y, Sonoyama T, Okada H, Yamamoto K. Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy. World J Gastroenterol 2012; 18:6674-6. [PMID: 23236244 PMCID: PMC3516216 DOI: 10.3748/wjg.v18.i45.6674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 07/27/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
Abstract
Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice. Recently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) using double-balloon enteroscopy (DBE) has been shown to be feasible and effective, even in patients with surgically altered anatomies. On the other hand, endoscopic partial stent-in-stent (PSIS) placement of self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible, safe and effective. We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success. This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization, even in patients with surgically altered anatomies.
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Prospective study of therapeutic spiral enteroscopy in patients with surgically altered anatomy. Surg Endosc 2012; 27:671-8. [DOI: 10.1007/s00464-012-2485-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 06/19/2012] [Indexed: 12/19/2022]
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Mönkemüller K. Should we illuminate the black box of the small bowel mucosa from above or below? Clin Gastroenterol Hepatol 2012; 10:917-9. [PMID: 22610001 DOI: 10.1016/j.cgh.2012.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 04/26/2012] [Indexed: 02/06/2023]
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Koshitani T, Matsuda S, Takai K, Motoyoshi T, Nishikata M, Yamashita Y, Kirishima T, Yoshinami N, Shintani H, Yoshikawa T. Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2012; 18:3765-9. [PMID: 22851872 PMCID: PMC3406432 DOI: 10.3748/wjg.v18.i28.3765] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 11/21/2011] [Accepted: 04/22/2012] [Indexed: 02/06/2023] Open
Abstract
Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.
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Abstract
For most ERCP endoscopists, the greatest hurdle to a successful procedure is deep cannulation of the bile duct. This article explores basic cannulation technique, then reviews a variety of instruments and techniques designed to increase the average endoscopist's success rate. Expert ERCP endoscopists have a few favorite techniques that have proved reliable over time. The most frequently used ones are highlighted in this review.
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Affiliation(s)
- John Baillie
- Carteret Medical Group, 300 Penny Lane, Morehead City, NC 28557, USA.
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Lenz P, Domagk D. Double- vs. single-balloon vs. spiral enteroscopy. Best Pract Res Clin Gastroenterol 2012; 26:303-13. [PMID: 22704572 DOI: 10.1016/j.bpg.2012.01.021] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 01/19/2012] [Indexed: 01/31/2023]
Abstract
Starting with the introduction of the double-balloon enteroscope in 2001, two more techniques have been successfully developed for small bowel investigation (single-balloon enteroscopy, spiral enteroscopy). To compare the different enteroscopy systems, within this review, 68 studies were analyzed and put into context. The procedural characteristics (mean insertion depth, diagnostic yields, adverse events) were comparable for DBE, SBE or SE. The higher panenteroscopy rate in DBE might not have any clinical relevance. Therapeutic procedures, such as argon-plasma coagulation, polypectomy, dilation therapy and foreign body extraction are described with the DBE and SBE procedure. With regard to the present literature, the balloon-assisted devices as well as spiral enteroscopy technique seem to be equally suitable in clinical routine for imaging of the small bowel. The choice of the method should be based on availability, physicians' experience and clinical implications. Future randomized, controlled trials with large numbers of patients are needed to work out the subtleties of every single method.
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Affiliation(s)
- Philipp Lenz
- Department of Medicine B, University of Muenster, Albert-Schweitzer-Campus 1, A1, 48149 Muenster, Germany.
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Altered anatomy: enteroscopy and ERCP procedure. Best Pract Res Clin Gastroenterol 2012; 26:347-57. [PMID: 22704576 DOI: 10.1016/j.bpg.2012.03.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 03/05/2012] [Accepted: 03/06/2012] [Indexed: 01/31/2023]
Abstract
Roux-en-Y entero-enteric anastomosis of the small bowel is a commonly used surgical technique. However, it excludes the afferent limb and the biliopancreatic system from conventional endoscopic access. Recent data have shown that device-assisted enteroscopy (DAE) allows endoscopic retrograde cholangiopancreatography (ERCP) in these patients with high success rates. Both Double-balloon, short Double-balloon, Single-balloon and Spiral enteroscopy can be used for DAE-ERCP with comparable success. This review highlights the currently available literature data on DAE-ERCP in patients with Roux-en-Y anastomosis, and discusses the clinical aspects and technical difficulties. Although DAE does increase ERCP efficacy in patients with Roux-en-Y anastomosis, it remains a challenging procedure which is open to further improvement.
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Teshima CW, May G. Small bowel enteroscopy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:269-75. [PMID: 22590700 PMCID: PMC3352842 DOI: 10.1155/2012/571235] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 07/25/2011] [Indexed: 12/17/2022]
Abstract
Over the past decade, the advent of capsule endoscopy and balloon-assisted enteroscopy has revolutionized the approach to small intestinal diseases. The small bowel is no longer out of reach, and has fallen within the diagnostic and therapeutic realm of the gastrointestinal endoscopist. Double-balloon enteroscopy was the first type of balloon-assisted endoscopy and is the method for which there are the most data. Single-balloon enteroscopy has since been introduced as an alternative balloon-assisted method, followed more recently by the development of spiral overtube-assisted enteroscopy. The purpose of the present article is to review these methods of small bowel enteroscopy and to discuss the latest developments. While the investigation of small bowel diseases cannot be addressed without considering the central role of capsule endoscopy, a detailed assessment is beyond the scope of the present article, and capsule endoscopy will only be discussed as it pertains to enteroscopy.
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Affiliation(s)
- Christopher W Teshima
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta T6G 2X8, Canada.
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