Single‐ and double‐balloon enteroscopy‐assisted endoscopic retrograde cholangiopancreatography in patients with Roux‐en‐Y plus hepaticojejunostomy anastomosis and Whipple resection

Abstract

Background and Aim:In patients with Roux-en-Y hepaticojejunostomy (HJ with R-Y) and Whipple resection, endoscopic retrograde cholangiopancreatography (ERCP) can be challenging. We report our experience with ERCP using balloon-assisted enteroscopy (BAE) (BAE-ERCP) in patients with HJ with R-Y, and Whipple resection.Methods: BAE-ERCP procedures were carried out in 62 patients (HJ with R-Y : Whipple resection = 34:28).Results: Overall, the rates of reaching the anastomosis were 85.3% (29/34) in HJ with R-Y and 96.4% (27/28) in Whipple resection. In terms of HJ with R-Y, insertion success rate by standard single-balloon enteroscopy (SBE) was 89.3% (25/28). Insertion success rate by short BAE, including SBE and double-balloon enteroscopy (DBE), was 50% (3/6). There was a statistically significant difference of insertion success rate between standard long BE and short BE (P = 0.021). However, in the Whipple patients, insertion success rate by standard and short SBE was 93.8% (15/16) and 91.7% (11/12), respectively. Initial insertion success rate by short BAE in Whipple patients was significantly higher than in HJ with R-Y (91.7% vs 50%, P = 0.045). Therapeutic interventions included dilation of anastomosis stricture, stone extraction, endoscopic mechanical lithotripsy, biliary stent placement, stent extraction, endoscopic nasobiliary drainage, direct cholangioscopy, and electrohydraulic lithotripsy. Our HJ with R-Y series and Whipple series treatment success rate was 90% (18/20) and 95.0% (19/20), respectively.Conclusions: BAE-ERCP enabled ERCP to be carried out in patients with HJ. It is considered safe and feasible. Further experience and device improvement are needed.

Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Pancreaticoduodenectomy: A Single-Center Experience

“…A study that used the short DBE for ERCP in 26 patients with PD reported a 100 % of ERCP success rate [11]. Finally, ERCP using either the standard or short SBE was successful in 92.9 % of 28 patients with PD [12].…”

“…Even though there are some PD patients who have Roux-en Y reconstruction and jejunojejunostomy [18], most have simpler gastrojejunostomy or duodenojejunostomy and single-loop reconstruction without jejunojejunostomy [16]. Itokawa et al [12] reported that the success rate of endoscope insertion with short balloon enteroscope was higher in PD patients than in hepatojejunostomy with Roux-en Y anastomosis (91.7 vs. 50 %) and suggested that Roux-en Y anastomosis may preclude deep scope insertion because of the long afferent loop and acute angulation. Consequently, BAE is not absolutely required in all patients with PD.…”

“…These studies reported relatively high success rate for biliary indications but poor success rate for pancreas indications. Recently, single-balloon-and double-balloonassisted ERCP have been recognized as useful diagnostic and therapeutic tools in patients with surgically altered anatomy, including a variety of Roux-en-Y procedures and PD [9][10][11][12][13][14][15]. However, there are few studies that focus on the utility of balloon-assisted ERCP in patients with PD.…”

ERCP in Postsurgical Patients

“…One of the largest cohorts of patients who underwent ERCP after Whipple was reported by Itokawain in 2014 [ 55 ]. Using both long and short DBE and SBE, the authors achieved an afferent loop insertion rate of 89.3 %.…”

Bile Duct Drainage Using a Short Double-Balloon Endoscope for a Hematoma due to Hepatocellular Carcinoma After Roux-en-Y Reconstruction

“…A high successful intubation rate in the blind end in patients with surgically altered anatomy has been reported using a balloonassisted endoscope [5,6] . In patients with a Roux-en-Y anastomosis, indigo carmine injection at the duodenum is useful to identify the afferent limb [1] .…”