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Han S, Kolb JM, Edmundowicz SA, Attwell AR, Hammad HT, Wani S, Shah RJ. The Success and Safety of Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Gastrointestinal Anatomy. Med Sci (Basel) 2025; 13:18. [PMID: 39982243 PMCID: PMC11843866 DOI: 10.3390/medsci13010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Revised: 02/06/2025] [Accepted: 02/08/2025] [Indexed: 02/22/2025] Open
Abstract
BACKGROUND/OBJECTIVES Performing endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered gastrointestinal anatomy remains challenging, frequently necessitating the use of forward-viewing endoscopes. Given the challenge in endoscope selection based on the type of altered anatomy, the aim of this study was to examine ERCP success rates by specific endoscopes for different anatomy types. METHODS This single-center retrospective study examined ERCPs performed in patients with surgically altered gastrointestinal anatomy during an 18-year period. Enteroscopy success, cannulation success, and intervention success rates were compared between the different anatomy and endoscope types. RESULTS This study included a total of 334 adult patients (665 total ERCPs) with altered anatomy. The pediatric colonoscope was most frequently utilized (32.2%), and the majority of procedures were performed for biliary indications. Enteroscopy success was 82.2% in Roux-en-Y gastric bypass (RYGB), 97% in Billroth II, 91.5% in Whipple, and 93.2% in Roux-en-Y hepaticojejunostomy (RYHJ). Cannulation success was 90.5% in RYGB, 90.5% in Billroth II, 83.6% in Whipple, and 90.6% in RYHJ. Intervention success was 88.2% in Billroth II, 65.1% in RYGB, 81.6% in Whipple, and 87.5% in RYHJ. In patients with RYGB and RYHJ, SBE was utilized most frequently, with rotational enteroscopy having the highest success rates. The overall adverse event rate was 5.1%, with the majority of these being mild in severity. CONCLUSIONS This large retrospective study found ERCP with forward-viewing endoscopes to be safe and effective for a variety of surgically altered anatomy types. Despite recent advances seen with endoscopic ultrasound-guided drainage procedures, this study advocates for ERCP as the initial approach for pancreaticobiliary access in surgically altered anatomy.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Jennifer M. Kolb
- Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA 90024, USA;
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (S.A.E.); (A.R.A.); (H.T.H.); (S.W.)
| | - Augustin R. Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (S.A.E.); (A.R.A.); (H.T.H.); (S.W.)
| | - Hazem T. Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (S.A.E.); (A.R.A.); (H.T.H.); (S.W.)
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (S.A.E.); (A.R.A.); (H.T.H.); (S.W.)
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (S.A.E.); (A.R.A.); (H.T.H.); (S.W.)
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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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Wang RY, Fan Z. Progress in minimally invasive treatment of biliary pancreatic duct obstruction after digestive tract reconstruction by endoscopic retrograde cholangiopancreatography. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:490-500. [DOI: 10.11569/wcjd.v32.i7.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2024]
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Semash KO. Post-liver transplant biliary complications. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2024; 26:72-90. [DOI: 10.15825/1995-1191-2024-3-72-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Biliary complications (BCs) are the most frequent complications following liver transplantation (LT). They are a major source of morbidity after LT. The incidence of BCs after LT is reported to range from 5% to 45%. The main post-LT biliary complications are strictures, biliary fistulas and bilomas, cholelithiasis, sphincter of Oddi dysfunction, hemobilia, and mucocele. Risk factors for biliary complications are diverse. In this article we seek to review the main types of biliary complications and modern approaches to their diagnosis and treatment.
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Ghandour B, Keane MG, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Sharaiha RZ, Kowalski TE, Khashab MA, Shrigiriwar A, Zhang L, Mony S, Khan A, Loren DE, Chiang A, Schlachterman A, Kumar A, Saab O, Blake B, Obri MS. Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study. Gastrointest Endosc 2023; 97:260-267. [PMID: 36228699 DOI: 10.1016/j.gie.2022.09.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure. METHODS This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%). CONCLUSIONS Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson Hospital, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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El Djouzi S. Endoscopic Evaluation of the Bariatric Surgery Patient. THE SAGES MANUAL OF PHYSIOLOGIC EVALUATION OF FOREGUT DISEASES 2023:215-233. [DOI: 10.1007/978-3-031-39199-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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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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Ghandour B, Shinn B, Dawod QM, Fansa S, El Chafic AH, Irani SS, Pawa R, Gutta A, Ichkhanian Y, Paranandi B, Pawa S, Al-Haddad MA, Zuchelli T, Huggett MT, Bejjani M, Sharaiha RZ, Kowalski TE, Khashab MA. EUS-directed transgastric interventions in Roux-en-Y gastric bypass anatomy: a multicenter experience. Gastrointest Endosc 2022; 96:630-638. [PMID: 35623383 DOI: 10.1016/j.gie.2022.05.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach allows for EUS-guided transgastric interventions (EDGIs) in patients with Roux-en-Y gastric bypass (RYGB). Although EUS-guided transgastric ERCP (EDGE) outcomes have been reported, data are scant on other endoscopic interventions. We aimed to evaluate the outcomes and safety of EDGIs. METHODS This retrospective study involved 9 centers (United States, 8; Europe, 1) and included patients with RYGB who underwent EDGIs between June 2015 and September 2021. The primary outcome was the technical success of EDGIs. Secondary outcomes were adverse events (AEs), length of hospital stay, and fistula follow-up and management. RESULTS Fifty-four EDGI procedures were performed in 47 patients (mean age, 61 years; 72% women), most commonly for the evaluation of a pancreatic mass (n = 16) and management of pancreatic fluid collections (n = 10). A 20-mm LAMS was used in 26 patients and a 15-mm LAMS in 21, creating a gastrogastrostomy in 37 patients and jejunogastrostomy in 10. Most patients (n = 30, 64%) underwent a dual-session EDGI, with a median interval of 17 days between the 2 procedures. Single-session EDGI was performed in 17 patients, of whom 10 (59%) had anchoring of the LAMS. The most common interventions were diagnostic EUS (with or without FNA or fine-needle biopsy sampling; n = 28) and EUS-guided cystgastrostomy (n = 8). The mean procedural time was 97.6 ± 78.9 minutes. Technical success was achieved in 52 patients (96%). AEs occurred in 5 patients (10.6%), of which only 1 AE (2.1%) was graded as severe. Intraprocedural LAMS migration was the most common AE, occurring in 3 patients (6.4%), whereas delayed spontaneous LAMS migration occurred in 2 (4.3%). Four of the 5 LAMS migration events were managed endoscopically, and 1 required surgical repair. LAMS anchoring was found to be protective against LAMS migration (P = .001). The median duration of hospital stay was 2.1 ± 3.7 days. Of the 17 patients who underwent objective fistula assessment endoscopically or radiologically after LAMS removal, 2 (11.7%) were found to have persistent fistulas. In 1 case the fistula was intentionally left open to assist with weight gain. The other fistula was successfully closed endoscopically. CONCLUSIONS EDGI is effective and safe for the diagnosis and management of pancreaticobiliary and foregut disorders in RYGB patients. It is associated with high rates of technical success and low rates of severe AEs. LAMS migration is the most common AE with evidence that anchoring can be protective against its occurrence. Persistent fistulas may occur, but endoscopic closure seems to be effective.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brianna Shinn
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Qais M Dawod
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Sima Fansa
- Department of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abdul Hamid El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center-New Orleans, New Orleans, Louisiana, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Aditya Gutta
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Bharat Paranandi
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Swati Pawa
- Division of Gastroenterology and Hepatology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, Michigan, USA
| | - Matthew T Huggett
- Division of Gastroenterology and Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Papasavas P, Docimo S, Oviedo RJ, Eisenberg D. Biliopancreatic access following anatomy-altering bariatric surgery: a literature review. Surg Obes Relat Dis 2022; 18:21-34. [PMID: 34688572 DOI: 10.1016/j.soard.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/19/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Pavlos Papasavas
- Division of Metabolic and Bariatric Surgery, Hartford Hospital, Hartford, Connecticut.
| | - Salvatore Docimo
- Division of Bariatric, Foregut, and Advanced GI Surgery, Stony Brook Medicine, Stony Brook, New York
| | | | - Dan Eisenberg
- Department of Surgery, Stanford University and Palo Alto VA Health Care Center, Palo Alto, California
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Chen X, Wang F, Liu J, Tao W, Zhang Z, Cao T, Fang J, Zhao Q. Risk factors for adverse events associated with endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a retrospective study. BMC Gastroenterol 2021; 21:448. [PMID: 34837996 PMCID: PMC8627619 DOI: 10.1186/s12876-021-02031-w] [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: 08/22/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be a challenge in patients with surgically altered anatomy. We aimed to identify the risk factors of ERCP-related adverse events in patients with surgically altered anatomy in our center. Methods We included patients with surgically altered anatomy who underwent ERCP between April 2017 and December 2020 at our center. Clinical characteristics and outcomes were analyzed in univariate and multivariate methods to identify the risk factors for adverse events. Results A total of 121 ERCP procedures were performed in 93 patients. The papilla or surgical anastomosis was successfully reached in 113 cases (93.4%). Diagnostic success was achieved in 106 cases (93.8%) and subsequent therapeutic success was achieved in 102 cases (96.2%). ERCP-related adverse events occurred in 31 cases (25.6%). In univariate analysis, not first time ERCP attempt, a CBD stone diameter ≥ 15 mm, multiple cannulation attempts, endoscopic papillary balloon dilation, endoscopic papillary large balloon dilation, endoscopic retrograde biliary drainage, biopsy in the bile duct or papilla, mechanical lithotripsy use, and stone retrieval basket were associated with ERCP-related adverse events. In multivariate analysis, multiple cannulation attempts (OR 5.283; 95% CI 1.088–25.659; p = 0.039), endoscopic papillary balloon dilation (OR 4.381; 95% CI 1.191–16.114; p = 0.026), and biopsy in the bile duct or papilla (OR 35.432; 95% CI 2.693–466.104; p = 0.007) were independently associated with ERCP-related adverse events. Conclusions ERCP in patients with surgically altered anatomy was feasible and safe. Interventions including multiple cannulation attempts, endoscopic papillary balloon dilation, and biopsy in the bile duct or papilla were independent risk factors for ERCP-related adverse events.
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Affiliation(s)
- Xiaojia Chen
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Fan Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Jing Liu
- Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wenhui Tao
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Zhang Zhang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Tingting Cao
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Jun Fang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China
| | - Qiu Zhao
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China. .,Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuhan, China.
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11
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Tarantino I, Rizzo GEM. Biliopancreatic Endoscopy in Altered Anatomy. MEDICINA-LITHUANIA 2021; 57:medicina57101014. [PMID: 34684051 PMCID: PMC8537222 DOI: 10.3390/medicina57101014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/17/2021] [Accepted: 09/22/2021] [Indexed: 12/31/2022]
Abstract
Background and Objectives: Anatomical post-surgical alterations of the upper gastrointestinal (GI) tract have always been challenging for performing diagnostic and therapeutic endoscopy, especially when biliopancreatic diseases are involved. Esophagectomy, gastrectomy with various reconstructions and pancreaticoduodenectomy are among the most common surgeries causing upper GI tract alterations. Technological improvements and new methods have increased the endoscopic success rate in these patients, and the literature has been rapidly increasing over the past few years. The aim of this systematic review is to identify evidence on the available biliopancreatic endoscopic techniques performed in the altered post-surgical anatomy of upper GI tract. Materials and Methods: We performed a systematic search of PubMed, MEDLINE, Cochrane Library, and SCOPUS databases. Study-level variables extracted were the last name of the first author, publication year, study design, number of patients, type of post-surgical anatomical alteration, endoscopic technique, success rate and endoscopic-related adverse events. Results: Our primary search identified 221 titles, which was expanded with studies after the citation search. The final full-text review process identified 52 articles (31 retrospective studies, 8 prospective studies and 13 case reports). We found several different techniques developed over the years for biliopancreatic diseases in altered anatomy, in order to perform both endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). They included enteroscopy-assisted ERCP (double and single balloon enteroscopy-ERCP, spiral enteroscopy-ERCP) laparoscopic assisted ERCP, EUS-Directed transgastric ERCP, EUS-directed transgastric intervention, gastric access temporary for endoscopy, and percutaneous assisted trans prosthetic endoscopic therapy. The success rate was high (most of the techniques showed a success rate over 90%) and a low rate of adverse events were reported. Conclusions: We suggest the considerationof the novel techniques when approaching patients with altered anatomy who require biliopancreatic endoscopy, focusing on the surgery type, success rate and adverse events reported in the literature.
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Affiliation(s)
- Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, 90127 Palermo, Italy;
- Correspondence:
| | - Giacomo Emanuele Maria Rizzo
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, 90127 Palermo, Italy;
- Section of Gastroenterology & Hepatology, Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, 90133 Palermo, Italy
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12
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Kim JH, Yang MJ. Recent advances of endoscopic retrograde cholangiopancreatography in surgically altered anatomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii210038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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13
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Cho E, Park CH, Kim Y, Cho SY. Impact of Scope Exchange from a Long Single Balloon Enteroscope to a Gastroscope during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy. Gut Liver 2021; 16:308-316. [PMID: 34140429 PMCID: PMC8924805 DOI: 10.5009/gnl210088] [Citation(s) in RCA: 2] [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: 03/02/2021] [Revised: 04/16/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022] Open
Abstract
Background/Aims Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) is challenging to gastrointestinal endoscopists. The aim of this study was to evaluate the impact of scope exchange from a long single balloon enteroscope (SBE) to a gastroscope during SBE-assisted ERCP (SBE-ERCP) in patients with SAA. Methods Patients who underwent SBE-ERCP between February 2019 and October 2020 were retrospectively identified. Intubation success, scope exchange success, cannulation success, and therapeutic success were analyzed along with complications. Results Fifty-six patients with various SAAs underwent SBE-ERCP procedures, including Billroth II subtotal gastrectomy (B-II, n=13), pylorus-preserving pancreato-duodenectomy (PPPD, n=6), Roux-en-Y hepaticojejunostomy (REY HJ, n=4), and total gastrectomy with REY anastomosis (TG REY, n=33). Overall intubation, cannulation, and therapeutic success rates were 89.3%, 82.1%, and 82.1%, respectively. Therapeutic success rates did not differ significantly among the type of SAA. Successful scope exchange rate after successful intubation was significantly higher in native papilla (B-II and TG REY, 83.3%, 35/42) compared to bilioenteric anastomosis (PPPD and REY HJ, 0%, 0/8, p<0.001). Intubation success, scope exchange, and cannulation success were associated with therapeutic success (p<0.001). In multivariate analysis, successful scope exchange was the only factor related to cannulation success (p=0.02). The major complication rate was 1.8% (one perforation). Conclusions SBE-ERCP is a safe and effective procedure to treat biliary problems in patients with SAA. Successful scope exchange may lead to higher therapeutic success by way of cannulation success.
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Affiliation(s)
- Eunae Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chang Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Youngjung Kim
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seo Yeon Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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14
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Elsharif M, Hague AG, Ahmed H, Ackroyd R. After you Roux, what do you do? A systematic review of most successful advanced assisted ERCP techniques in patients with various altered upper gastrointestinal surgical anatomical reconstructions with particular focus on RYGB (last 10 years). Clin J Gastroenterol 2020; 13:985-1009. [PMID: 32809134 DOI: 10.1007/s12328-020-01201-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023]
Abstract
Access to the Common Bile Duct in patients with surgically altered UGI anatomy such as RYGB is exceptionally challenging. Previously, these patients could only be treated by open surgery; however, multiple new advanced assisted ERCP techniques such as EDGE, LA-ERCP, and DEA-ERCP have now been developed and indeed successfully used to treat these patients. Despite growing experience, these techniques have yet to become part of our mainstream practice and many clinicians remain unfamiliar or even unaware of them; as a result, they are unfortunately often overlooked. We conducted this systematic review to try and shed more light on them and understand which of these techniques resulted in the best patient outcomes. We conducted a systematic review of PubMed database publications between December 2008 and December 2018. Keyword variants of "EDGE, Enteroscopy-assisted & laparoscopy-assisted ERCP" and "altered surgical anatomy" were combined to identify relevant papers for inclusion. We identified 34 studies, comprising a total of 1848 advanced assisted ERCPs in patients with altered UGI anatomy from 12 different countries. These papers were critically appraised, summarised, and presented in table format. EDGE and LA-ERCP were associated with both the highest overall combined CBD cannulation rates (99.3% for both vs 74.6% for DEA-ERCP) and ERCP interventional success (98.3% for EDGE vs 97.4% for LA-ERCP and 67.6% for DEA-ERCP). Advanced ERCP is associated with excellent success rates and a higher safety profile than surgery; however, patient selection and identification of the exact surgical anatomy are key.
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Affiliation(s)
- Mohamed Elsharif
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK.
| | - Adam Gary Hague
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
| | - Hussam Ahmed
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
| | - Roger Ackroyd
- Department of Upper GI Surgery, Northern General Hospital, Sheffield Teaching Hospitals, Flat 2, 23 Montgomery Road, Sheffield, S71LN, UK
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15
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Klair JS, Jayaraj M, Chandrasekar VT, Priyan H, Law J, Murali AR, Singh D, Larsen M, Irani S, Kozarek R, Ross A, Krishnamoorthi R. ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis. Endoscopy 2020; 52:824-832. [PMID: 32492751 DOI: 10.1055/a-1178-9741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events. METHODS We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone. RESULTS 10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted. CONCLUSIONS OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.
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Affiliation(s)
- Jagpal Singh Klair
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Mahendran Jayaraj
- Division of Gastroenterology and Hepatology, University of Nevada School of Medicine, Las Vegas, Nevada, United States
| | | | - Harshith Priyan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Joanna Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Dhruv Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
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16
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Ferretti F, Fraquelli M, Cantù P, Penagini R, Casazza G, Vecchi M, Orlando S, Invernizzi F, Branchi F, Donato FM, Elli L. Efficacy and safety of device-assisted enteroscopy ERCP in liver transplantation: A systematic review and meta-analysis. Clin Transplant 2020; 34:e13864. [PMID: 32236978 DOI: 10.1111/ctr.13864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 03/14/2020] [Accepted: 03/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Enterobiliary anastomoses are the main source of complications after liver transplantation. An endoscopic approach combining device-assisted enteroscopy and ERCP (DAE-ERCP) is technically feasible in postsurgical anatomy. AIMS This study aimed at assessing the efficacy, feasibility, and safety of DAE-ERCP in liver-transplanted patients (LT) and other subsets (non-LT). METHODS A systematic review and meta-analysis of studies involving DAE procedures in LT patients (between January 2000 and May 2017) was conducted. The main endpoints were as follows: endoscopic, diagnostic, therapeutic, and overall success rates, complications, and the need for surgery. RESULTS A total of 155 studies were retrieved, and 6 relevant trials were analyzed. Overall, 132 subjects (72 LT and 60 non-LT) undergoing 257 DAE-ERCP (135 and 122) were included. Complications were rare (4/257), and no deaths occurred. These are the pooled success rates among LT and non-LT patients: 80%-100% and 82%-95% (enteroscopic), 75%-100% and 89%-100% (diagnostic), 67%-100% and 92%-100% (therapeutic), and 60%-100% and 79%-83% (overall results). The requirement for surgery was similar in the two subgroups. CONCLUSION In managing biliary complications, the high diagnostic and therapeutic success rates of DAE-ERCP combined with its safety and feasibility encourage its application as a first-line approach to transplanted patients.
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Affiliation(s)
- Francesca Ferretti
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Mirella Fraquelli
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Cantù
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche Luigi Sacco, Università degli Studi di Milano, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Stefania Orlando
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Invernizzi
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, A.M. & A. Migliavacca Center for Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Federica Branchi
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Francesca Maria Donato
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, A.M. & A. Migliavacca Center for Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Center for Prevention and Diagnosis of Celiac Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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17
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Krutsri C, Kida M, Yamauchi H, Iwai T, Imaizumi H, Koizumi W. Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. World J Gastroenterol 2019; 25:3313-3333. [PMID: 31341358 PMCID: PMC6639547 DOI: 10.3748/wjg.v25.i26.3313] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/18/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.
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Affiliation(s)
- Chonlada Krutsri
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Mitsuhiro Kida
- Department of Gastroenterology, Graduate School of Medicine, Kitasato University Hospital, Kanagawa 252-0375, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Graduate School of Medicine, Kitasato University Hospital, Kanagawa 252-0375, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Graduate School of Medicine, Kitasato University Hospital, Kanagawa 252-0375, Japan
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Graduate School of Medicine, Kitasato University Hospital, Kanagawa 252-0375, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Graduate School of Medicine, Kitasato University Hospital, Kanagawa 252-0375, Japan
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18
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Bukhari M, Kowalski T, Nieto J, Kunda R, Ahuja NK, Irani S, Shah A, Loren D, Brewer O, Sanaei O, Chen YI, Ngamruengphong S, Kumbhari V, Singh V, Aridi HD, Khashab MA. An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc 2018; 88:486-494. [PMID: 29730228 DOI: 10.1016/j.gie.2018.04.2356] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 04/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ERCP is challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy. EUS-guided gastrogastrostomy (GG) creation is a promising novel technique to access the excluded stomach to facilitate conventional ERCP. We aimed to compare procedural outcomes and adverse events (AEs) between EUS-guided GG-assisted ERCP (EUS-GG-ERCP) and enteroscopy-assisted ERCP (e-ERCP) in patients with RYGB. METHODS Patients with RYGB anatomy who underwent EUS-GG-ERCP or e-ERCP between 2014 and 2016 at 5 tertiary centers were included. The primary outcome was technical success of ERCP, defined as successful cannulation of the selected duct with successful intervention as intended. Secondary outcomes included total procedural time (in the EUS-GG group, total procedural time included EUS-GG creation plus ERCP procedure time), length of hospital stay, and rate/severity of AEs graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS A total of 60 patients (mean age, 57.2 ± 13.2; 75% women) were included, of whom 30 (50%) underwent EUS-GG-ERCP and 30 (50%) underwent e-ERCP (double-balloon enteroscope ERCP, 19; single-balloon enteroscope ERCP, 11). The technical success rate was significantly higher in the EUS-GG-ERCP versus the e-ERCP group (100% vs 60.0%, P < .001). Total procedure time was significantly shorter in patients who underwent EUS-GG-ERCP (49.8 minutes vs 90.7 minutes, P < .001). Postprocedure median length of hospitalization was shorter in the EUS-GG group (1 vs 10.5 days, P = .02). Rate of AEs was similar in both groups (10% vs 6.7%, P = 1). CONCLUSIONS EUS-GG-ERCP may be superior to e-ERCP in patients with RYGB anatomy in terms of a higher technical success and shorter procedural times and offers a similar safety profile.
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Affiliation(s)
- Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA; Division of Medicine and Gastroenterology and Hepatology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Thomas Kowalski
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jose Nieto
- Borland-Groover Clinic, Jacksonville, Florida, USA
| | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Apeksha Shah
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Loren
- Division of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Olaya Brewer
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Hanaa Dakour Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Arapis K, Donatelli G, Tammaro P, Ribeiro Parenti L, Marmuse JP, Hansel B. Janeway Gastrostomy for Trans-gastric ERCP: an Emergency Alternative Method to Access the Excluded Structures. Obes Surg 2018; 28:2916-2917. [PMID: 29909513 DOI: 10.1007/s11695-018-3349-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Konstantinos Arapis
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France. .,Paris Diderot University-Sorbonne Paris Cité, Paris, France.
| | - Gianfranco Donatelli
- Department of Gastroenterology and Hepatology, Hôpital Privé des Peupliers, 8 place de l'Abbé G. Hénocque, 75013, Paris, France
| | - Pascuale Tammaro
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France
| | - Lara Ribeiro Parenti
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Jean Pierre Marmuse
- Department of Surgery, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48, rue Henri Hussard, 75018, Paris, France.,Paris Diderot University-Sorbonne Paris Cité, Paris, France
| | - Boris Hansel
- Paris Diderot University-Sorbonne Paris Cité, Paris, France.,Department of Endocrinology, Diabetology, Nutrition, Hôpitaux Universitaires Paris-Nord Val de Seine, Hôpital Bichat-Claude-Bernard, 48 rue Henri Hussard, 75018, Paris, France
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Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN. Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc 2018; 87:1241-1247. [PMID: 29317267 DOI: 10.1016/j.gie.2017.12.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 12/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. METHODS This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. RESULTS Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. CONCLUSION With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.
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Affiliation(s)
- Mohammad F Ali
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | - Rani Modayil
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | - Krishna C Gurram
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | | | - David Friedel
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
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Verscheure D, Gianfranco D, Tammaro P, Dumont JL, Marmuse JP, Arapis K. Access to excluded structures after Roux-en-Y gastric bypass: Experience in a high-level bariatric center without a technical platform for endoscopic retrograde cholangiopancreatography. J Visc Surg 2017; 155:195-200. [PMID: 29221786 DOI: 10.1016/j.jviscsurg.2017.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rapid weight loss after bariatric surgery is associated with a high prevalence of gallstone formation. In laparoscopic Roux-en-Y gastric bypass (RYGBP), the bypassed segment is not readily available for endoscopic or radiographic examination. We propose a laparoscopic Janeway gastrostomy for secondary access to excluded structures in bariatric centers with no mandatory technical equipment in endoscopic retrograde cholangiopancreatography (ERCP), double-balloon ERCP or spiral enteroscopy. METHOD This was a single-institution retrospective review of a prospectively collected database of patients with a history of laparoscopic RYGBP who underwent laparoscopic Janeway gastrostomy for duodenal and biliary access. The operative indications, technical aspects, endoscopic findings, outcomes, and complications were investigated. RESULTS Five patients with a history of RYGBP underwent laparoscopic Janeway gastrostomy for exploration of the bypassed segment. All of them had biliary pathology, and all underwent successful ERCP and papillotomy. The gastrostomies were closed secondarily. The mean duration of hospitalization was 12 days. No complications developed. All procedures were performed laparoscopically. CONCLUSION If access to excluded structures and simultaneous ERCP was not possible, temporary laparoscopic Janeway gastrostomy could be the last option alternative for a staged ERCP to gain access to the bypassed structures. It is a feasible and safe solution for the exploration and treatment of patients with a history of RYGBP in bariatric centers that have no endoscopists with expertise in ERCP.
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Affiliation(s)
- D Verscheure
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
| | - D Gianfranco
- Department of gastroenterology and hepatology, hôpital privé des Peupliers, 8, place de l'Abbé G.-Hénocque, 75013 Paris, France.
| | - P Tammaro
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
| | - J L Dumont
- Department of gastroenterology and hepatology, hôpital privé des Peupliers, 8, place de l'Abbé G.-Hénocque, 75013 Paris, France.
| | - J P Marmuse
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
| | - K Arapis
- Department of general and digestive surgery, university hospital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex 18, France.
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Management of biliary anastomotic strictures after liver transplantation. Transplant Rev (Orlando) 2017; 31:207-217. [DOI: 10.1016/j.trre.2017.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/06/2017] [Accepted: 03/19/2017] [Indexed: 12/13/2022]
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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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Abstract
PURPOSE OF REVIEW Endoscopic technology has evolved such that device-assisted enteroscopes (DAEs) are readily available and utilized to diagnose and treat patients with small bowel disease. In this review, we briefly discuss the DAE platforms and the expanding role for small bowel enteroscopy. RECENT FINDINGS The indications for small bowel endoscopy are rapidly increasing with new diagnostic and therapeutic maneuvers that are allowing patients to obtain treatments that would have otherwise required more invasive or higher risk procedures. The evolving utilization of DAE tools in patients with altered gastrointestinal anatomy and otherwise palliative conditions is allowing for more aggressive and therapeutic choices for patients who would otherwise have limited options. SUMMARY There are currently four different platforms for small bowel endoscopy each with different operational characteristics. The literature comparing double-balloon and single-balloon enteroscopy is relatively established, but there are still limited data evaluating the role of the two newer platforms (spiral and on-demand enteroscopy) in diagnostic and therapeutic small bowel endoscopy - a reflection of the potential and vast opportunities that are available in the field of small bowel enteroscopy.
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25
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De Koning M, Moreels TG. Comparison of double-balloon and single-balloon enteroscope for therapeutic endoscopic retrograde cholangiography after Roux-en-Y small bowel surgery. BMC Gastroenterol 2016; 16:98. [PMID: 27549034 PMCID: PMC4994384 DOI: 10.1186/s12876-016-0512-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 08/03/2016] [Indexed: 02/08/2023] Open
Abstract
Background Roux-en-Y reconstructive surgery excludes the biliopancreatic system from conventional endoscopic access. Balloon-assisted enteroscopy allows therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in these patients, avoiding rescue surgery. The objective of the current study is to compare success and complication rate of double-balloon (DBE) and single-balloon enteroscope (SBE) to perform ERCP in Roux-en-Y patients. Methods Seventy three Roux-en-Y patients with suspected biliary tract pathology underwent balloon-assisted enteroscopy in a tertiary-care center. Retrospective analysis of 95 consecutive therapeutic ERCP procedures was performed to define and compare success and complication rate of DBE and SBE. Results Male-female ratio was 28/45 with a mean age of 58 ± 2 years. 30 (32 %) procedures were performed with DBE and 65 (68 %) with SBE. Overall ERCP success rate was 73 % for DBE and 75 % for SBE (P = 0.831). Failure was due to inability to reach or cannulate the intact papilla or bilioenteric anastomosis. Success rate was significantly higher when performed at the bilioenteric anastomosis (80 % success in 56 procedures) or at the intact papilla in short-limb Roux-en-Y (80 % in 15 procedures) as compared to the intact papilla in long-limb (58 % in 24 procedures; P = 0.040). Adverse event rates were 10 % (DBE) and 8 % (SBE) (P = 0.707) and mostly dealt with conservatively. Conclusions ERCP after Roux-en-Y altered small bowel anatomy is feasible and safe using both DBE and SBE. Both techniques are equally competent with high success rates and acceptable adverse events rates. ERCP at the level of the intact papilla in long limb Roux-en-Y is less successful as compared to short-limb or bilioenteric anastomosis.
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Affiliation(s)
- Michael De Koning
- Department of Gastroenterology & Hepatology, Antwerp University Hospital, Wilrijkstraat 10, B-2650, Antwerp, Belgium
| | - Tom G Moreels
- Department of Gastroenterology & Hepatology, Antwerp University Hospital, Wilrijkstraat 10, B-2650, Antwerp, Belgium.
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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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Alqahtani MS, Alshammary SA, Alqahtani EM, Bojal SA, Alaidh A, Osian G. Hepaticojejunostomy for the management of sump syndrome arising from choledochoduodenostomy in a patient who underwent bariatric Roux-en-Y gastric bypass: A case report. Int J Surg Case Rep 2016; 21:36-40. [PMID: 26921534 PMCID: PMC4802126 DOI: 10.1016/j.ijscr.2016.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/02/2016] [Accepted: 02/04/2016] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Rapid weight loss following bariatric surgery is associated with high incidence of gallstones and complications that may need bilioenteric diversion. This presents a specific challenge in the management of this group of patients. CASE PRESENTATION A 37 years old female underwent a Roux-en-Y gastric bypass (RYGB) in 2008 for morbid obesity. In 2009 she presented with obstructive jaundice and was diagnosed with choledocholithiasis successfully managed by open cholecystectomy and choledochoduodenostomy. In the following years, she developed recurrent attacks of fever, chills, jaundice, and right upper quadrant pain and her weight loss was not satisfactory. Imaging of the liver showed multiple cholangitic abscesses. Reflux at the choledochoduodenostomy site was suggestive of sump syndrome as a cause of her recurrent cholangitis and a definitive surgical treatment was indicated. Intraoperative findings confirmed sump at the choledochoduodenostomy site and also revealed the presence of a large superficial accessory duct arising from segment four of the liver with separate drainage into the duodenum distal to the choledochoduodenostomy site. A formal hepaticojejunostomy was done after ductoplasty. The Roux limb was created by transecting the jejunum 40cm distal to the foot anastomosis of the RYGB. The gastric limb was lengthened as part of this procedure which afforded the patient the additional benefit of weight loss. CONCLUSION Choledochoduodenostomy should be avoided in patients with RYGB due to the risk of sump syndrome which requires conversion to a formal hepaticojejunostomy.
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Affiliation(s)
- Mohammed S Alqahtani
- Hepatobiliary Section, Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia.
| | - Shadi A Alshammary
- Hepatobiliary Section, Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia
| | - Enas M Alqahtani
- Hepatobiliary Section, Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia
| | - Shoukat A Bojal
- Hepatobiliary Section, Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia
| | - Amal Alaidh
- Hepatobiliary Section, Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia
| | - Gelu Osian
- Hepatobiliary Section, Department of Surgery, King Fahad Specialist Hospital, Dammam 31444, Saudi Arabia
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Kurzynske FC, Romagnuolo J, Brock AS. Success of single-balloon enteroscopy in patients with surgically altered anatomy. Gastrointest Endosc 2015; 82:319-24. [PMID: 25841583 DOI: 10.1016/j.gie.2015.01.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/04/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Single-balloon enteroscopy (SBE) was introduced in 2007 to diagnose and treat small-bowel disorders. No study to date has evaluated SBE in patients with surgically altered anatomy outside of ERCP. OBJECTIVE To evaluate the efficacy, yield, and safety of SBE in patients with surgically altered anatomy. DESIGN Retrospective study. SETTING Tertiary-care academic medical center. PATIENTS All patients with altered surgical anatomy who underwent SBE at the Medical University of South Carolina from July 2007 to September 2013. INTERVENTIONS SBE. MAIN OUTCOME MEASUREMENTS Diagnostic yield, therapeutic yield, technical success, and adverse events. RESULTS A total of 48 patients met inclusion criteria. Mean age was 56 years (77% female). Eleven patients underwent single-balloon PEG placement, 8 single-balloon ERCP, 22 non-PEG/non-ERCP anterograde SBE, and 7 retrograde SBE. Previous surgeries included Roux-en-Y gastric bypass (n=26), small-intestine resection (n=6), colon resection (n=5), Whipple procedure (n=4), choledochojejunostomy (n=3), hepaticojejunostomy (n=1), Billroth I (n=1), Billroth II (n=1), and Puestow procedure (n=1). Procedural indications were PEG tube placement (n=11), choledocholithiasis (n=2), biliary stricture (n=2), obstructive jaundice (n=1), cholangitis (n=1), ampullary mass (n=1), sphincter of Oddi dysfunction (n=1), anemia and/or bleeding (n=15), abdominal pain (n=9), radiologic evidence of obstruction (n=3), and Peutz-Jeghers syndrome (n=2). The technical success rate was 73% in single-balloon PEG placement, 88% in single-balloon ERCP, 82% in other anterograde SBEs, and 86% in retrograde SBEs. No intraprocedural or postprocedural adverse events were observed. LIMITATIONS Single center, retrospective study. CONCLUSION SBE is safe and effective in patients with surgically altered anatomy.
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Affiliation(s)
- Frank C Kurzynske
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrew S Brock
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
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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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Abu Dayyeh B. Single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy: getting there. Gastrointest Endosc 2015; 82:20-3. [PMID: 26074035 DOI: 10.1016/j.gie.2015.03.1988] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 03/31/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Barham Abu Dayyeh
- Division of Hepatology and Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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31
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Inamdar S, Slattery E, Sejpal DV, Miller LS, Pleskow DK, Berzin TM, Trindade AJ. Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc 2015; 82:9-19. [PMID: 25922248 DOI: 10.1016/j.gie.2015.02.013] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/07/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgically altered pancreaticobiliary anatomy increases the difficulty of performing ERCP. Single-balloon enteroscopy (SBE) is a relatively new technique that can be used for ERCP in patients with surgically altered anatomy. OBJECTIVE To evaluate the therapeutic and diagnostic success of SBE-ERCP among patients with surgically altered anatomy. DESIGN/SETTING Systematic review and meta-analysis of studies involving SBE-ERCP in patients with Roux-en-Y gastric bypass, hepaticojejunostomy, or Whipple procedure. Enteroscopy success was defined as success in reaching the papilla and/or biliary anastomosis by using SBE. Diagnostic success was defined as obtaining a cholangiogram. Procedural success was defined as the ability to provide successful intervention, if appropriate. A random-effects model was used. RESULTS A total of 461 patients underwent SBE-ERCP from 15 trials. The pooled enteroscopy, diagnostic, and procedural success rates were 80.9% (95% confidence interval [CI], 75.3%-86.4%), 69.4% (95% CI, 61.0%-77.9%), and 61.7% (95% CI, 52.9%-70.5%), respectively. There was statistical large heterogeneity for enteroscopy, diagnostic, and therapeutic success (P < .001 for all). Adverse events occurred in 6.5% (95% CI, 4.7%-9.1%) of patients. There was no evidence of publication bias in this meta-analysis. LIMITATIONS Our findings and interpretations are limited by the quantity and heterogeneity of the studies included in the analysis. CONCLUSION SBE-ERCP has high diagnostic and procedural success rates in this challenging patient population. It should be considered a first-line intervention when biliary access is required after Roux-en-Y gastric bypass, hepaticojejunostomy, or Whipple procedure.
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Affiliation(s)
- Sumant Inamdar
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA
| | - Eoin Slattery
- Department of Preventive Medicine and Nutrition, Columbia University Medical Center, New York, New York, USA
| | - Divyesh V Sejpal
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA
| | - Larry S Miller
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA
| | - Douglas K Pleskow
- The Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tyler M Berzin
- The Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Arvind J Trindade
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA; The Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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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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Girotra M, Soota K, Klair JS, Dang SM, Aduli F. Endoscopic management of post-liver transplant biliary complications. World J Gastrointest Endosc 2015; 7:446-459. [PMID: 25992185 PMCID: PMC4436914 DOI: 10.4253/wjge.v7.i5.446] [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: 09/30/2014] [Revised: 11/15/2014] [Accepted: 02/04/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.
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Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Pasha SF, Saltzman JR, Shaukat A, Wang A, Stefanidis D, Richardson WS, Kothari SN, Cash BD. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 2015; 81:1063-1072. [PMID: 25733126 DOI: 10.1016/j.gie.2014.09.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/11/2014] [Indexed: 12/22/2022]
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Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Pasha SF, Saltzman JR, Shaukat A, Wang A, Stefanidis D, Richardson WS, Khothari SN, Cash BD. The role of endoscopy in the bariatric surgery patient. Surg Obes Relat Dis 2015; 11:507-517. [PMID: 26093766 DOI: 10.1016/j.soard.2015.02.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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ASGE STANDARDS OF PRACTICE COMMITTEE. The role of endoscopy in the bariatric surgery patient. Surg Endosc 2015; 29:1007-1017. [PMID: 26038784 DOI: 10.1007/s00464-015-4111-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015; 81:795-803. [PMID: 25665931 DOI: 10.1016/j.gie.2014.11.019] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/29/2022]
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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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Abstract
Extraction of common bile duct stones by endoscopic retrograde cholangiopancreatography generally involves biliary sphincterotomy, endoscopic papillary balloon dilation or a combination of both. Endoscopic papillary large-balloon dilation after sphincterotomy has increased the safety of large stone extraction. Cholangioscopically directed electrohydraulic and laser lithotripsy using single-operator mother-daughter systems or direct peroral cholangioscopy using ultraslim endoscopes are increasingly utilized for the management of refractory stones. In this Review, we focus on advances in endoscopic approaches and techniques, with a special emphasis on management strategies for 'difficult' common bile duct stones.
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Cosgrove ND, Wang AY. Endoscopic approaches to biliary intervention in patients with surgically altered gastroduodenal anatomy. World J Surg Proced 2014; 4:23-32. [DOI: 10.5412/wjsp.v4.i2.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/01/2014] [Accepted: 03/18/2014] [Indexed: 02/06/2023] Open
Abstract
Over the past decade the ability of endoscopists to access the biliary tree in patients with surgically altered gastroduodenal anatomy has significantly advanced. Much of the progress has occurred as a result of the development of better tools to navigate the deep small bowel, such as single-balloon- (SBE), double-balloon- (DBE), and spiral-enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP). However, despite using a cap, accessing the papilla or bile duct using these forward-viewing enteroscopy platforms remains challenging, even in expert hands. In patients with Roux-en-Y gastric bypass (RYGB) anatomy, the excluded stomach is a potential point of access for either a delayed transgastric- or immediate laparoscopy-assisted-ERCP approach. However, the parallel advancement of therapeutic endoscopic ultrasound (EUS) also provides alternative approaches through which the biliary system can be accessed and intervened on in patients with surgically altered anatomies. Generally speaking, in patients with short gastro-jejunal “Roux” and bilio-pancreatic limbs, ideally less than 150 cm in length, starting with a (cap-assisted) push-enteroscopy or balloon-enteroscopy approach would offer reasonable diagnostic and therapeutic ERCP success. When available, short-SBE or short-DBE scopes should be used, as they allow the use of conventional ERCP equipment, are associated with shorter procedure times, and are easier to manipulate. In patients with RYGB who have longer Roux and/or bilio-pancreatic limbs (> 150 cm in total length), or in patients who have failed prior attempts at deep enteroscopy-assisted ERCP, transgastric laparoscopy-assisted-ERCP is associated with higher rates of diagnostic and therapeutic success as compared to deep-enteroscopy-assisted ERCP. Finally, EUS-guided biliary access for antegrade biliary intervention or for rendezvous enteroscopy-assisted ERCP is possible. While percutaneous transhepatic biliary drainage and surgical bile duct exploration remain viable alternatives, these methods are not without significant morbidity and mortality and should only be considered if less invasive endoscopic interventions are not feasible or appropriate.
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Lenze F, Meister T, Matern P, Heinzow HS, Domschke W, Ullerich H. Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography in patients with surgically altered anatomy: higher failure rate in malignant biliary obstruction - a prospective single center cohort analysis. Scand J Gastroenterol 2014; 49:766-71. [PMID: 24694357 DOI: 10.3109/00365521.2014.904397] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The performance of endoscopic retrograde cholangiopancreaticography (ERCP) in patients with post-surgically altered anatomy is technically ambitious. Our study aimed at comparing a cohort of patients having successfully undergone single-balloon enteroscopy (SBE)-assisted ERCP to those in whom SBE-ERCP failed. METHODS This trial is a prospective single center cohort study. Participants included 30 patients (median age 69.5 years, range 20-86 years) with previous pancreaticobiliary surgery. First, a conventional ERCP approach was attempted in all patients. Additionally, those patients in whom prior conventional ERCP had failed underwent SBE-ERCP (n = 26). Patients' baseline characteristics were retrieved and patient cohorts with and without successful SBE-ERCPs were compared and analyzed. Statistical analysis was applied. Univariate analysis was performed to detect possible risk factors of SBE-ERCP failure. RESULTS The overall success rate of SBE-ERCP, including two patients with percutaneous transhepatic cholangiography- assisted rendezvous technique was 65.4% (17/26). Patients with malignant obstructive cholestasis had a significantly higher failure rate compared to those with benign strictures (84.2% vs. 14.2%, p < 0.001). DISCUSSION SBE-ERCP is a promising tool for diagnostic and therapeutic procedures in the pancreaticobiliary system of selected, previously operated patients with failure of conventional ERCP. However, higher failure rates in malignant biliary obstruction should be taken into account.
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Affiliation(s)
- Frank Lenze
- Department of Medicine B, University of Muenster , Muenster , Germany
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Abstract
Biliary disease is common in the obese population and increases after bariatric surgery. This article reviews management of the gallbladder at the time of bariatric surgery, as well as imaging modalities in the bariatric surgery population and prevention of lithogenesis in the rapid weight loss phase. In addition, diagnosis and treatment options for biliary diseases are discussed, including laparoscopic-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography in the patient having bariatric surgery.
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Affiliation(s)
- Brandon T Grover
- Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA
| | - Shanu N Kothari
- Department of General and Vascular Surgery, Gundersen Health System, 1900 South Avenue, C05-001, La Crosse, WI 54601, USA.
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Tomizawa Y, Sullivan CT, Gelrud A. Single balloon enteroscopy (SBE) assisted therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with roux-en-y anastomosis. Dig Dis Sci 2014; 59:465-70. [PMID: 24185681 DOI: 10.1007/s10620-013-2916-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/05/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis is a complex challenge. Long length of afferent limb after an acute angle at the jejunojejunostomy and altered location of the biliary orifice make biliary cannulation difficult. Single balloon enteroscopy assisted ERCP (SBE-ERCP) is a promising alternative to conventional approaches. AIM The purpose of this study was to assess the efficacy and safety of SBE-ERCP in patients with Roux-en-Y reconstruction at a high volume tertiary referral center. METHODS This is a retrospective cohort study. All procedures were performed by a single, experienced pancreatobiliary endoscopist. Patient demographics and related clinical data were obtained. The rate of procedure successes and complications were determined. RESULTS Fourteen patients (nine women) with a median age of 63 years (range 35-83 years) underwent 22 SBE-ERCP procedures from March 2009 to May 2011. Surgically altered anatomy consisted of Whipple procedure (n = 4), hepaticojejunostomy (n = 9) and partial gastrectomy (n = 1). Indications for SBE-ERCP were obstructive jaundice (n = 10), cholangitis (n = 7), post-PTC internalization (n = 3) and biliary stent extraction/exchange (n = 2). The hepaticojejunostomy site (HJS) was reached in 15 (68 %) procedures. Successful interventions were performed in 11 (73 %) of 15 cases, including balloon dilation of biliary strictures (n = 3), insertion of biliary stents (n = 7), retrieval of biliopancreatic stents (n = 4) and biliary stone extraction (n = 4). The mean procedural time for successful interventions was 97.6 min (range 73-147 min). No procedural complications occurred during the median follow-up of 501 days (range 22-1,242 days). CONCLUSION SBE-ERCP is safe and carries an acceptable success rate in experienced hands.
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Affiliation(s)
- Yutaka Tomizawa
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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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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Okuno M, Iwashita T, Yasuda I, Mabuchi M, Uemura S, Nakashima M, Doi S, Adachi S, Mukai T, Moriwaki H. Percutaneous transgallbladder rendezvous for enteroscopic management of choledocholithiasis in patients with surgically altered anatomy. Scand J Gastroenterol 2013; 48:974-8. [PMID: 23782350 DOI: 10.3109/00365521.2013.805812] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy (SAA) is generally challenging despite the use of enteroscopy. After failed biliary cannulation, rendezvous technique (RV) can be an option to assist the biliary access. However, proper needle puncture of biliary ducts, which is critical in the RV procedure, can be difficult because of insufficient biliary dilation. By contrast, the gallbladder can be punctured as a possible access route for RV. AIM To evaluate the feasibility and safety of percutaneous transgallbladder (PTGB)-RV in patients with SAA. PATIENTS AND METHODS Six patients who underwent PTGB-RV were included. PTGB drainage was performed in cases without sufficient biliary duct dilation. A guidewire was inserted through the PTGB route with antegrade passage through the cystic duct, common bile duct and duodenal papilla. An enteroscope was inserted up to the papilla, at the guidewire exit site. The guidewire was pulled out through the accessory channel followed by biliary cannulation over the guidewire and endoscopic papillary balloon dilation (EPBD) for stone removal. RESULTS Six patients with SAA (Roux-en-Y in 4 and Billroth-II in 2) underwent PTGB-RV for removal of bile duct stones. In all patients, a guidewire was successfully inserted into the duodenum followed by insertion of the enteroscope and biliary cannulation. EPBD was then performed, but subsequent stone removal failed in 1 patient. Stone removal was successful in 5 patients without complication, except 1 case of mild pancreatitis. CONCLUSION PTGB-RV seems to be a feasible and relatively safe salvage technique in patients with SAA.
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Affiliation(s)
- Mitsuru Okuno
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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Iwashita T, Yasuda I, Doi S, Uemura S, Mabuchi M, Okuno M, Mukai T, Itoi T, Moriwaki H. Endoscopic ultrasound-guided antegrade treatments for biliary disorders in patients with surgically altered anatomy. Dig Dis Sci 2013; 58:2417-22. [PMID: 23535877 DOI: 10.1007/s10620-013-2645-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 03/11/2013] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy is challenging. Several endoscopic ultrasound (EUS)-guided biliary access techniques have been reported as effective alternatives. EUS-guided antegrade treatments (AG) have been developed more recently but have not yet been studied well. AIMS To evaluate the feasibility and safety of EUS-AG for biliary disorders in patients with surgically altered anatomies. METHODS We retrospectively identified all the patients who underwent EUS-AG. The left intrahepatic bile duct (IHBD) was initially punctured from the intestine followed by cholangiography, antegrade guidewire manipulation, and bougie dilation of the fistula. Either antegrade biliary stenting (ABS) or antegrade balloon dilation (ABD) was performed depending on the biliary disorders. In stone cases, the stones were antegradely pushed out using a balloon. After ABD, a nasobiliary drainage tube was placed to prevent possible bile leak and to keep an access route for any possible repeat procedures. RESULTS EUS-AG was attempted in seven patients including choledocholithiasis in five, malignant biliary obstruction in one, and bilioenteric anastomosis stricture in one. EUS-AG was not performed in one patient because EUS-cholangiography did not indicate the presence of stones. In the remaining six patients, the IHBD was successfully punctured, followed by cholangiography, guidewire insertion, and bougie dilation. ABS and ABD were successfully performed in one and five patients, respectively. Antegrade procedures with ABD were repeated twice in one patient. Mild complications were observed in two patients. CONCLUSIONS EUS-AG for biliary disorders in patients with surgically altered anatomy is feasible. Further studies are warranted.
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Affiliation(s)
- Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
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Iwashita T, Yasuda I, Doi S, Uemura S, Mabuchi M, Okuno M, Mukai T, Itoi T, Moriwaki H. Endoscopic ultrasound-guided antegrade treatments for biliary disorders in patients with surgically altered anatomy. Dig Dis Sci 2013. [PMID: 23535877 DOI: 10.1016/j.gie.2013.03.1219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy is challenging. Several endoscopic ultrasound (EUS)-guided biliary access techniques have been reported as effective alternatives. EUS-guided antegrade treatments (AG) have been developed more recently but have not yet been studied well. AIMS To evaluate the feasibility and safety of EUS-AG for biliary disorders in patients with surgically altered anatomies. METHODS We retrospectively identified all the patients who underwent EUS-AG. The left intrahepatic bile duct (IHBD) was initially punctured from the intestine followed by cholangiography, antegrade guidewire manipulation, and bougie dilation of the fistula. Either antegrade biliary stenting (ABS) or antegrade balloon dilation (ABD) was performed depending on the biliary disorders. In stone cases, the stones were antegradely pushed out using a balloon. After ABD, a nasobiliary drainage tube was placed to prevent possible bile leak and to keep an access route for any possible repeat procedures. RESULTS EUS-AG was attempted in seven patients including choledocholithiasis in five, malignant biliary obstruction in one, and bilioenteric anastomosis stricture in one. EUS-AG was not performed in one patient because EUS-cholangiography did not indicate the presence of stones. In the remaining six patients, the IHBD was successfully punctured, followed by cholangiography, guidewire insertion, and bougie dilation. ABS and ABD were successfully performed in one and five patients, respectively. Antegrade procedures with ABD were repeated twice in one patient. Mild complications were observed in two patients. CONCLUSIONS EUS-AG for biliary disorders in patients with surgically altered anatomy is feasible. Further studies are warranted.
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Affiliation(s)
- Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
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Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, Bakis G, Jonnalagadda SS, Al-Lehibi AA, Hardy A, Morgan DR, Sethi A, Stevens PD, Akerman PA, Thakkar SJ, Brauer BC. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013; 77:593-600. [PMID: 23290720 DOI: 10.1016/j.gie.2012.10.015] [Citation(s) in RCA: 199] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 10/20/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Data on overtube-assisted enteroscopy to facilitate ERCP in patients with surgically altered pancreaticobiliary anatomy, or long-limb surgical bypass, is limited. OBJECTIVE To evaluate and compare ERCP success by using single-balloon (SBE), double-balloon (DBE), or rotational overtube enteroscopy. DESIGN Consecutive patients identified retrospectively. SETTING Eight U.S. referral centers. PATIENTS Long-limb surgical bypass patients with suspected pancreaticobiliary diseases. INTERVENTION Overtube-assisted enteroscopy ERCP. MAIN OUTCOME MEASUREMENTS Enteroscopy success: visualizing the pancreaticobiliary-enteric anastomosis or papilla. ERCP success: completing the intended pancreaticobiliary intervention. Clinical success: greater than 50% reduction in abdominal pain or level of hepatic enzyme elevations or resolution of jaundice. RESULTS From January 2008 through October 2009, 129 patients had 180 enteroscopy-ERCPs. Anatomy was Roux-en-Y: gastric bypass (n = 63), hepaticojejunostomy (n = 45), postgastrectomy (n = 6), Whipple procedure (n = 10), and other (n = 5). ERCP success was 81 of 129 (63%). Enteroscopy success: 92 of 129 (71%), of whom 81 of 92 (88%) achieved ERCP success. Reasons for ERCP failure (n = 48): afferent limb entered but pancreaticobiliary anastomosis and/or papilla not reached (n = 23), cannulation failure (n = 11), afferent limb angulation (n = 8), and jejunojejunostomy not identified (n = 6). Select interventions: anastomotic stricturoplasty (cautery ± dilation, n = 16), stone removal (n = 21), stent (n = 25), and direct cholangioscopy (n = 11). ERCP success rates were similar between Roux-en-Y gastric bypass and other long-limb surgical bypass and among SBE, DBE, and rotational overtube enteroscopy. Complications were 16 of 129, 12.4%. LIMITATIONS Retrospective study. CONCLUSION (1) ERCP is successful in nearly two-thirds of long-limb surgical bypass patients and in 88% when the papilla or pancreaticobiliary-enteric anastomosis is reached. (2) Enteroscopy success in long-limb surgical bypass is similar among SBE, DBE, and rotational overtube enteroscopy methods. (3) Referral of long-limb surgical bypass patients who require ERCP to high-volume institutions may be considered before more invasive percutaneous or surgical alternatives.
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Affiliation(s)
- Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
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Azeem N, Tabibian JH, Baron TH, Orhurhu V, Rosen CB, Petersen BT, Gostout CJ, Topazian MD, Levy MJ. Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis. Gastrointest Endosc 2013; 77:568-577. [PMID: 23369652 DOI: 10.1016/j.gie.2012.11.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 11/23/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiography (ERC) is technically challenging in liver transplant patients with Roux-en-Y biliary anastomosis. The optimal endoscope for such cases remains unknown. OBJECTIVE Compare efficacy and safety of performing ERC in liver transplant patients with Roux-en-Y biliary anastomosis by using an adult colonoscope (AC), a pediatric colonoscope (PC), and a single-balloon enteroscope (SBE). DESIGN Retrospective chart review. SETTING Tertiary-care referral center. PATIENTS Liver transplant patients with Roux-en-Y biliary anastomoses. INTERVENTION ERC with AC, PC, and SBE. MAIN OUTCOME MEASUREMENTS Rates of reaching the afferent limb and biliary anastomosis; rates of cannulation; rates of diagnostic, therapeutic, and procedural success; and number of adverse events. RESULTS Ninety patients underwent 199 ERCs from 2002 to 2012; 86 with an AC, 55 with a PC, and 58 with an SBE. Biliary cannulation and diagnostic, therapeutic, and procedural success rates were all significantly higher with an SBE than with a PC. Among patients undergoing the initial ERC, no statistical difference was found among SBE, the PC, and an AC. However, the rate of procedural success with SBE during initial ERC over the last 4 years has increased. Of 25 total failures with ACs, exchange for SBEs resulted in procedural success in 4 of 4 attempts. Of 22 failures with a PC, exchange for an SBE resulted in success in 3 of 4 cases. Of 4 failures with SBE exchange in 6 cases (4 to AC, 2 to PC), SBE resulted in success in only 1. No adverse events occurred directly related to type of endoscope. LIMITATIONS Retrospective study, single center, lack of standardized approach to selection of endoscopes, uncontrolled variables (general anesthesia, learning curve). CONCLUSION In liver transplant patients with Roux-en-Y anatomy, rates of biliary cannulation, therapeutic success, and procedural success are higher with use of an SBE than with a PC and tend to be higher compared with use of an AC among the overall cohort. Use of an SBE and procedural success rates with SBEs have increased over the last 4 years. Failed cases with either an AC or PC can be completed if exchanged for an SBE.
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Affiliation(s)
- Nabeel Azeem
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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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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