Single-Balloon Enteroscopy—Guided ERCP in Surgically Altered Anatomy Is Safe and Highly Effective: Results from a Prospective Study

Abstract

Objectives Single-balloon enteroscopy (SBE)—assisted endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be cost effective and less technically demanding than other modes of device-assisted enteroscopy. We aimed to evaluate the safety and efficacy of SBE-ERCP in surgically altered anatomy. Methods This was a prospective cohort study in a high-volume tertiary care gastroenterology center. Patients with surgically altered anatomy requiring pancreaticobiliary interventions, who failed ERCP with a colonoscope/duodenoscope, underwent SBE-ERCP. Diagnostic and therapeutic success, procedure time, and adverse events were evaluated prospectively with short-term follow-up. Results Twenty-eight patients with surgically altered anatomy (19 males, aged 15–66 years) underwent total 40 SBE-ERCP (23 Roux-en-Y, 17 Billroth II anatomy) procedures. The ERCP diagnosis were hepaticojejunostomy (HJ) stricture (N = 10), HJ stricture and stone (N = 7), common bile duct (CBD) stricture (N = 6), CBD stone (N = 1), pancreaticojejunostomy (PJ) stricture (N = 1), and pancreatic duct (PD) stricture (N = 1). Diagnostic success was achieved in 91.3% (21/23) patients with Roux-en-Y anatomy and 100% (17/17) with Billroth II anatomy. Therapeutic success was achieved in 86.95% (20/23) and 94.1% (16/17) patients with Roux-en-Y and Billroth II anatomy, respectively. In patients with intact papilla (N = 8), diagnostic and therapeutic success were achieved in 100% (8/8) and 75% (6/8) cases, respectively. The mean procedure time for Roux-en-Y and Billroth II anatomy were 64.95 minutes (range 30–110 min) and 38.31 minutes (range 25–60 min), respectively. Immediate complications occurred in 7.5% (3/40) procedures (2 requiring laparotomy, 1 treated endoscopically) in the form of perforation. Among delayed complications, 5 patients had cholangitis and 1 had recurrent cholestasis, which were successfully treated with stent exchange. No other complications occurred over median follow-up of 110 days (30–390 d). Conclusion SBE-ERCP in surgically altered anatomy requiring pancreatic–biliary intervention appears safe and highly effective with current long ERCP accessories. Further improvement in SBE-ERCP technique and accessories has the potential to make it a promising avenue in surgically altered anatomy.

Outcomes of Endoscopic Biliary Drainage in Postsurgical Anatomy Using Endoscopic Ultrasound and Enteroscopy: A Comparative Study

“…In the SBE-ERCP group, stents were mostly plastic and of smaller caliber, and the obstructions were often incomplete, potentially leading to cholangitis. [15][16][17][18] A meta-analysis comparing endoscopic drainage with PTBD showed that although PTBD had a higher success rate, it was associated with more stent migrations, repeated interventions, and recurrent cholangitis. Another randomized controlled study comparing EUS-guided biliary drainage and PTBD in malignant biliary obstruction with failed ERCP revealed fewer complications, reinterventions, and adverse events in the EUS group compared to PTBD.…”

“…In the SBE-ERCP group, stents were mostly plastic and of smaller caliber, and the obstructions were often incomplete, potentially leading to cholangitis. 15 16 17 18…”

Role of Endoscopy in Managing Complications Associated with Pancreaticoduodenectomy: Concise Review of Literature

“…Therapeutic success was achieved in 86.95 and 94.1% of patients with Roux-en-Y and Billroth II anatomy with an immediate complication rate of 7.5% in the form of perforation. 52 In another study by Garcés-Durán, feasibility and safety of SBE-ERCP in post-PD anatomy were assessed; 34 patients underwent 106 SBE-ERCP, 76 procedures performed for biliary indication had a 90% technical success and 88% clinical success rate, whereas among 30 procedures performed for pancreatic intervention technical success rate was 80% and the clinical success rate was 65%. 53 While either side-view or forward-viewing scopes can be used, passage of a side-view scope into the afferent limb is often tricky.…”