How to not get lost in the labyrinth during device‐assisted enteroscopy endoscopic retrograde cholangiopancreatography

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-established modality for diagnostic and therapeutic maneuvers in various pancreaticobiliary disorders, with a success rate of over 95% in patients with normal anatomy. However, patients with surgically altered anatomy who require ERCP pose unique challenges. These include identifying and accessing the afferent limb, maneuvering around acutely angled anastomoses, identifying the papilla or pancreaticobiliary anastomosis, and cannulation of the native papilla or stenotic anastomosis without the benefit of the elevator mechanism. Patients with Billroth II reconstruction may undergo successful ERCP using conventional endoscopes such as side-viewing, forward-viewing, and anterior oblique-viewing. However, in patients with Rouxen-Y reconstruction, access to the papilla or pancreaticobiliary anastomosis can be extremely difficult or impossible, even by using a push enteroscope or pediatric colonoscope. Recently, with the advent of device-assisted enteroscopy (DAE), such as single balloon, double balloon, and spiral enteroscopy, various endoscopic pancreaticobiliary interventions can be performed with a relatively high success rate, even in patients with Roux-en-Y reconstruction. [1][2][3][4][5] However, even using DAE, endoscopists are sometimes faced with difficulty identifying the Y anastomosis or afferent limb in patients with Roux-en-Y reconstruction, as if they got lost in a labyrinth. If endoscopists are exhausted because of time consumed in endoscope insertion due to difficulty identifying the Y anastomosis or afferent limb, their fatigue may affect the performance of the ERCP procedures after reaching the papilla or pancreaticobiliary anastomosis.Several techniques have been reported to advance the endoscope to the correct route at the jejunojejunal anastomosis during balloon endoscopy-assisted ERCP (BE-ERCP). [6][7][8][9] Yano et al. 6 reported a technique to identify the afferent limb by sprinkling indigo carmine into the intestine on the oral side of the Y anastomosis, evaluating the influx of indigo carmine into both limbs at the Y anastomosis, and judging the one with less influx to be the