Diagnostic and Therapeutic Double-Balloon Enteroscopy after Small Bowel Roux-en-Y Reconstructive Surgery

Abstract

Background: Roux-en-Y reconstruction excludes the afferent limb and the biliopancreatic system from conventional endoscopic access. Postoperative problems in these excluded gastrointestinal systems are therefore often dealt with surgically. We investigated the usefulness of the therapeutic double-balloon enteroscope to perform interventional endoscopic procedures in the excluded segment of the gastrointestinal tract after Roux-en-Y reconstruction. Methods: 30 procedures were performed in 22 patients with Roux-en-Y reconstruction after enterobiliary anastomosis, gastrectomy or bariatric gastric bypass. All procedures were performed with the therapeutic double-balloon enteroscope, under general anesthesia and with fluoroscopic control. Results: ERCP at the enterobiliary anastomosis was successful in 90% (n = 10) of the procedures. ERCP at the intact papilla was successful in 60% (n = 5). Enterocutaneous fistula closure after (sub)total gastrectomy was performed in 2 procedures. Successful diagnostic procedures encompassed intubation of the excluded stomach after bariatric gastric bypass (89%, n = 9) or the afferent limb after Roux-en-Y reconstruction (75%, n = 4). The overall success rate in accessing the aimed excluded segment with the double-balloon enteroscope was 87%. Interventional procedures were able to avoid surgery in 65%. One retroperitoneal perforation occurred during ERCP which was conservatively treated. Conclusions: Excluded gastrointestinal segments after Roux-en-Y reconstruction can be accessed with a substantial success rate using double-balloon enteroscopy. Therapeutic interventions like ERCP can prevent surgery in the majority of patients.

Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: A practical classification

“…0, 1, 2 and 3) ( Table 2). Endoscopically, the HJ orifice can appear as small (type A) (Figure 1), large (type B) (Figure 2), normal (C) and double (i.e., separate anastomosis for the left and right hepatic ducts) (D) [17] . Of note, the endoscopic appearance allows classification of the HJ-orifice at the level of the lumen or above it.…”

“…therapeutic ERCP with the BAE in patients with altered bowel anatomy is feasible, allowing for the localization of the afferent limb, visualization of the HJ or papilla of Vater and demonstration of anastomotic strictures or bile duct stones of the choledochojejunostomy [5][6][7][8][9][10][11][12][13][14][15][16][17]19] . Besides diagnostic capabilities, BAE-ERCP also permits therapeutic interventions such as sphincterotomy, biliary stent placement, biliary balloon dilation and stent extraction [5][6][7][8][9][10][11][12][13][14][15][16][17][18] . Anastomotic strictures account for the majority of secondary long-term complications of hepaticojejunostomies such as hepaticolithiasis (stones in the hepatic duct), liver abscess and secondary biliary cirrhosis if left untreated [2,3] .…”

“…Nevertheless, performing an endoscopic retrograde cholangio pancreatography (ERCP) in these patients is technically very challenging or impossible, frequently mandating an operative intervention. However, the advent of balloon-assisted enteroscopy (BAE) [4] has increased our ability to reach the HJ located in the excluded limb and perform diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] . During BAE-ERC, we have observed that the HJ and biliary tree have specific appearances (i.e., patterns).…”

The Role of Overtube-assisted Deep Enteroscopy ERCP in Roux-en-Y Gastric Bypass Patients

“…A multicenter study by Siddiqui et al performed ERCPs in 39 RYGB patients using the 'short' double balloon enteroscope (EC-450BI5; Fujinon), achieving successful bile duct cannulation in 29 of the 32 patients in whom the papilla/surgical anastomoses was reached.A full spectrum of therapeutic maneuvers was performed, including sphincterotomy, stone extraction, balloon dilation, and the insertion of plastic/metal stents [20][21][22][23][24][25].Additionally, studies have been done by Moreels et al [22] and Patel et al [26] demonstrating the feasibility of diagnostic and therapeutic DBE-ERCP in large cohorts of patients who had undergone a variety of of Roux-en-Y reconstructive surgeries.These studies along with others are summarized in Table 2.…”

Role of Endoscopy in Laparoscopic Procedures

“…This technique was successful in two-thirds of the enrolled patients [44]. Another described technique includes the use of the double balloon enteroscopy for ERCP.The feasibility of this technique was illustrated in many case series with a success rate of 80-90% in cannulating the common bile duct (CBD) and a more than 60% success rate in performing therapeutic intervention of the biliary tract [45][46][47]. The use of double balloon enteroscopy offers the advantage of exploration of the afferent limb in less time;, however, the lack of elevator could be problematic in gaining deep access of the CBD, especially in patients with naive papilla.…”