Identification of retrograde peristalsis determines the afferent limb during double-balloon ERCP: the tidal wave sign

Accurate endoscopic identification of the afferent limb at the Y anastomosis using the fold disruption sign after gastric resection with Roux‐en‐Y reconstruction

“…Among several technical issues specific to BE-ERCP, scope insertion to the target lumen is the initial concern. Several methodologies for inferring the correct route have been reported, [1][2][3] resulting in better accuracy in comparison to random insertion. 1 Yano et al 2 have reported a confirmation technique using indigo carmine sprinkled at the oralside intestine, which is expected to flow only toward the anal side without reflux into the afferent limb, with an accuracy rate of 70.2%.…”

“…2 Iwasaki et al have reported another confirmation method using optical observation of intestinal peristaltic motions with an accuracy rate of 83.9%. 3 We discovered that the intestinal folds at the anastomosis could be used to predict the afferent limb. For RY reconstruction with gastric resection, the jejunum is cut and lifted up to be anastomosed to the oral tract (usually to the esophagus or stomach) near the cut end, and then it is longitudinally slit at its midpoint to create the Y anastomosis with the afferent limb.…”

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

“…Tsutsumi et al 8 reported that in patients with Roux-en-Y hepaticojejunostomy who underwent sideto-side jejunostomy if three-pronged lumens could be identified at the anastomosis, the endoscope could be advanced to the central lumen, which is the afferent limb. Iwasaki et al 9 focused on the difference in the direction of peristalsis between the afferent and efferent limb at the Y anastomosis. The finding of intestinal mucosal involvement in the attachment seen in retrograde peristalsis was named the "tidal wave sign", and the lumen that was positive for this sign was judged to be the afferent limb, with an accuracy rate of 83.9%.…”

“…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…”

“…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…”