A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video)

Raj J. Shah, Maximiliano Smolkin, Roy Yen, Andrew Ross, Richard A. Kozarek, Douglas A. Howell, Gennadiy Bakis, Sreenivasan S. Jonnalagadda, Abed A. Al-Lehibi, Al Hardy, Douglas R. Morgan, Amrita Sethi, Peter D. Stevens, Paul A. Akerman, Shyam J. Thakkar, Brian C. Brauer

Research output: Contribution to journalArticle

134 Scopus citations

Abstract

Background: Data on overtube-assisted enteroscopy to facilitate ERCP in patients with surgically altered pancreaticobiliary anatomy, or long-limb surgical bypass, is limited. Objective: To evaluate and compare ERCP success by using single-balloon (SBE), double-balloon (DBE), or rotational overtube enteroscopy. Design: Consecutive patients identified retrospectively. Setting: Eight U.S. referral centers. Patients: Long-limb surgical bypass patients with suspected pancreaticobiliary diseases. Intervention: Overtube-assisted enteroscopy ERCP. Main Outcome Measurements: Enteroscopy success: visualizing the pancreaticobiliary-enteric anastomosis or papilla. ERCP success: completing the intended pancreaticobiliary intervention. Clinical success: greater than 50% reduction in abdominal pain or level of hepatic enzyme elevations or resolution of jaundice. Results: From January 2008 through October 2009, 129 patients had 180 enteroscopy-ERCPs. Anatomy was Roux-en-Y: gastric bypass (n = 63), hepaticojejunostomy (n = 45), postgastrectomy (n = 6), Whipple procedure (n = 10), and other (n = 5). ERCP success was 81 of 129 (63%). Enteroscopy success: 92 of 129 (71%), of whom 81 of 92 (88%) achieved ERCP success. Reasons for ERCP failure (n = 48): afferent limb entered but pancreaticobiliary anastomosis and/or papilla not reached (n = 23), cannulation failure (n = 11), afferent limb angulation (n = 8), and jejunojejunostomy not identified (n = 6). Select interventions: anastomotic stricturoplasty (cautery ± dilation, n = 16), stone removal (n = 21), stent (n = 25), and direct cholangioscopy (n = 11). ERCP success rates were similar between Roux-en-Y gastric bypass and other long-limb surgical bypass and among SBE, DBE, and rotational overtube enteroscopy. Complications were 16 of 129, 12.4%. Limitations: Retrospective study. Conclusion: (1) ERCP is successful in nearly two-thirds of long-limb surgical bypass patients and in 88% when the papilla or pancreaticobiliary-enteric anastomosis is reached. (2) Enteroscopy success in long-limb surgical bypass is similar among SBE, DBE, and rotational overtube enteroscopy methods. (3) Referral of long-limb surgical bypass patients who require ERCP to high-volume institutions may be considered before more invasive percutaneous or surgical alternatives.

Original languageEnglish (US)
Pages (from-to)593-600
Number of pages8
JournalGastrointestinal endoscopy
Volume77
Issue number4
DOIs
StatePublished - Apr 1 2013

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Gastroenterology

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    Shah, R. J., Smolkin, M., Yen, R., Ross, A., Kozarek, R. A., Howell, D. A., Bakis, G., Jonnalagadda, S. S., Al-Lehibi, A. A., Hardy, A., Morgan, D. R., Sethi, A., Stevens, P. D., Akerman, P. A., Thakkar, S. J., & Brauer, B. C. (2013). A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointestinal endoscopy, 77(4), 593-600. https://doi.org/10.1016/j.gie.2012.10.015