Double balloon enteroscopy for endoscopic retrograde cholangiopancreaticography after Roux-en-Y reconstruction: case series and review of the literature

BACKGROUND: Endoscopic access to the biliary system can be difficult in patients with surgically altered anatomy, such as a Roux-en-Y reconstruction. Double balloon enteroscopy (DBE) is a relatively new procedure that enables access to the small bowel. DBE has recently been advocated as a method for endoscopic retrograde cholangiopancreaticography (ERCP) in patients with surgical reconstructions, with the potential to perform diagnostic and therapeutic interventions. METHODS: In three patients with a hepaticojejunostomy and Roux-en-Y reconstruction, the experiences using DBE to perform ERCP are described. The literature on DB-ERCP in patients with a Roux-en-Y reconstruction was reviewed. RESULTS: In all patients, the Roux limb was entered and a diagnostic cholangiography was carried out. In one patient, endoscopic therapy could be performed, consisting of balloon dilation of a stenotic biliodigestive anastomosis, repeated balloon dilation of biliary strictures and removal of bile casts. CONCLUSION: This series confirms recent data emerging from the literature that double balloon enteroscopy is a safe and feasible technique to obtain biliary access in patients with surgically altered anatomical configurations, such as those with a Roux-en-Y reconstruction. The diagnostic and therapeutic potential of DB-ERCP is great, and the utility of the procedure could be further improved if customised accessories become more widely available.     

Endoscopic Retrograde Cholangiopancreatography with Single-Balloon Enteroscopy Is Feasible in Patients with a Prior Roux-en-Y Anastomosis

The purpose of this study is to describe the feasibility of using single-balloon enteroscopy (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who had a prior Roux-en-Y (RY) anastomosis. This case series describes four patients, one with RY gastric bypass, two with RY due to bile duct injury, and one with RY after liver transplantation, who underwent ERCP with SBE. Cholangiography was successful in three of the four patients. In the procedure that was not successful, the enteroenterostomy site could not be located. The successful procedures ranged from 65–91 min in duration. Medication doses were higher than with typical ERCPs. No procedural complications occurred. SBE for ERCP is a feasible option for endoscopic access to the biliary tree in patients with prior RY anastomoses. Limitations of this technique include the time requirement, delay in identification of the enteroenterostomy site, potential learning curve, and immature technology lacking accessories.     

Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: Experience of multi-disciplinary collaboration

BACKGROUND Bilioenteric Roux-en-Y anastomosis is one of the most complicated approaches for reconstructing the gastrointestinal tract, and endoscopic retrograde cholangiopancreatography(ERCP) is technically challenging in patients after bilioenteric Roux-en-Y anastomosis. The optimal endoscopic strategies for such cases remain unknown.AIM To explore the feasibility and effectiveness of single balloon enteroscopy-assisted(SBE-assisted) therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis based on multi-disciplinary collaboration between endoscopists and surgeons as well as report the experience from China.METHODS This is a single center retrospective study. All of the SBE-assisted therapeutic ERCP procedures were performed by the collaboration between endoscopists and surgeons. The operation time, success rate, and complication rate were calculated.RESULTS Forty-six patients received a total of 64 SBE-assisted therapeutic ERCP procedures, with successful scope intubation in 60(93.8%) cases and successful diagnosis in 59(92.2%). All successfully diagnosed cases received successful therapy. None of the cases had perforation or bleeding during or after operation,and no post-ERCP pancreatitis occurred.CONCLUSION Based on multi-disciplinary collaboration, SBE-assisted therapeutic ERCP in patients after bilioenteric Roux-en-Y anastomosis is relatively safe and effective and has a high success rate.     

Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice. Recently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) using double-balloon enteroscopy (DBE) has been shown to be feasible and effective, even in patients with surgically altered anatomies. On the other hand, endoscopic partial stent-in-stent (PSIS) placement of self-expandable metallic stents (SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible, safe and effective. We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success. This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization, even in patients with surgically altered anatomies.     

Comparison between double-balloon and single-balloon enteroscopy in therapeutic ERC after Roux-en-Y entero-enteric anastomosis

AIM: To compare the efficacy of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE) in therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y entero-enteric anastomosis.METHODS: Retrospective analysis of our patient cohort revealed 4 patients with enterobiliary anastomosis and Roux-en-Y entero-enteric anastomosis who underwent repeated ERC with DBE and SBE because of recurrent cholangitis.RESULTS: A total of 38 endoscopic retrograde cholangiopancreatography procedures were performed in 25 patients with Roux-en-Y entero-enteric anastomosis. DBE was used in 29 procedures and SBE in 9. The 4 patients who underwent repeated ERC with DBE and SBE suffered from recurrent cholangitis due to stenosis of the enterobiliary anastomosis. ERC was performed repeatedly to achieve balloon dilation with/without biliary stone extraction and multiple stent placement at the level of the enterobiliary anastomosis. In all 4 patients DBE and SBE were equally successful. Compared to DBE, SBE was equally effective in passing the Roux-en-Y entero-enteric anastomosis, reaching the enterobiliary anastomosis and performing therapeutic ERC.CONCLUSION: This retrospective comparison shows that DBE and SBE are equally successful in the performance of therapeutic ERC at the level of the enterobiliary anastomosis after Roux-en-Y entero-enteric anastomosis.     

Spiral Assisted ERCP Is Equivalent to Single Balloon Assisted ERCP in Patients with Roux-en-Y Anatomy

Background  

Endoscopic retrograde cholangiopancreatography (ERCP) is often unsuccessful in patients with Roux-en-Y anatomy. Augmented enteroscopy allows deep insertion into the small bowel and can be useful in patients with Roux-en-Y anatomy. The aim of this study was to compare single balloon assisted ERCP (SBE-ERCP) and spiral assisted ERCP (SE-ERCP) in patients with Roux-en-Y anatomy in terms of diagnostic and therapeutic yield, procedure time, and complications.     

ERCP using double-balloon endoscopes in patients with Roux-en-Y anastomosis

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures are difficult to perform in patients with a Roux-en-Y reconstruction. Therefore, at present, at many institutions, ERCP is not generally performed for those with a Roux-en-Y anastomosis.

Methods

However, double-balloon endoscopes (DBEs) have dramatically changed this situation.

Results

The use of a DBE enables an endoscopic approach into the deeply situated small intestine, which has been difficult with a conventional endoscope. Therefore, ERCP for patients with a Roux-en-Y anastomosis has been attempted using a DBE, and good results have been reported.

Conclusion

The development of DBEs has created the possibility of performing ERCP for patients with Roux-en-Y reconstruction in whom an endoscopic approach has conventionally been believed to be difficult.     

Treatment of small-bowel diaphragm disease by using double-balloon enteroscopy

BACKGROUND: Double-balloon enteroscopy is a new technique that allows endoscopic therapy throughout the entire length of the small bowel. Diaphragm disease, characterized by thin septa that narrow the small-bowel lumen, is traditionally treated surgically by segmental resection. OBJECTIVE: To report successful endoscopic treatment of diaphragm disease by double-balloon enteroscopy. PATIENTS: Three patients. DESIGN: Case report. INTERVENTIONS: Double-balloon enteroscopy and stricture balloon dilation. RESULTS: We report, for the first time, 3 cases in which diaphragm strictures were successfully treated during double-balloon enteroscopy. In 2 cases, a retained capsule endoscope was removed by the retrograde approach after stricture dilation. LIMITATIONS: Small number of patients and brief length of patient follow up. CONCLUSION: Double-balloon enteroscopy may be used to treat patients with diaphragm disease, thus avoiding potentially complicated surgery.     

Enteral Access by Double-Balloon Enteroscopy: An Alternative Method of Direct Percutaneous Endoscopic Jejunostomy Placement

Background  

Although direct percutaneous endoscopic jejunal feeding tube placement is an increasingly accepted method of providing small-bowel access for long-term enteral nutrition, it is reliant on push enteroscopy and remains a technically challenging procedure with significant failure rates. Double-balloon enteroscopy, with its ability to provide controlled small-bowel intubation may facilitate direct percutaneous endoscopic jejunal tube placement.     

'Short' double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract

BACKGROUND:

Endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge for endoscopists in patients with surgically altered anatomy of the upper gastrointestinal tract. Double-balloon enteroscopes (DBEs) have revolutionized the ability to access the small bowel. The indication for its therapeutic use is expanding to include ERCP for patients who have undergone small bowel reconstruction. Most of the published experiences in DBE-assisted ERCP have used conventional double-balloon enteroscopes that are 200 cm in length, which do not permit use of the standard ERCP accessories. The authors report their experience with DBE-assisted ERCP using a ‘short’ DBE in patients with surgically altered anatomy.

METHODS:

A retrospective review of patients with previous small bowel reconstruction who underwent ERCP with a ‘short’ DBE at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (Toronto, Ontario) between February 2007 and November 2008 was performed.

RESULTS:

A total of 20 patients (10 men) with a mean age of 57.9 years (range 26 to 85 years) underwent 29 sessions of ERCP with a DBE. Six patients underwent Billroth II gastroenterostomy, seven patients Roux-en-Y hepaticojejunostomy, five patients Roux-en-Y gastrojejunostomy, one patient Roux-en-Y esophagojejunostomy and one patient a Whipple’s operation with choledochojejunostomy. Some patients (n=12 [60%]) underwent previous attempts at ERCP in which the papilla of Vater or bilioenteric anastomosis could not be reached with either a duodenoscope or pediatric colonoscope. All procedures were performed with a commercially available DBE (working length 152 cm, distal end diameter 9.4 mm, channel diameter 2.8 mm). The procedures were performed under conscious sedation with intravenous midazolam, fentanyl and diazepam, except in one patient in whom general anesthesia was administered. Either the papilla of Vater or bilioenteric anastomosis was reached in 25 of 29 cases (86.2%) in a mean duration of 20.8 min (range 5 min to 82 min). Bile duct cannulation was successful in 24 of 25 cases in which the papilla or bilioenteric anastomosis was reached. Therapeutic interventions were successful in 15 patients (24 procedures) including sphincterotomy (n=7), stone extraction (n=9), biliary dilation (n=8), stent placement (n=9) and stent removal (n=8). The mean total duration of the procedures was 70.7 min (range 30 min to 117 min). There were no procedure-related complications.

CONCLUSION:

DBEs enable successful diagnostic and therapeutic ERCP in patients with a surgically altered anatomy of the upper gastrointestinal tract. It is a safe, feasible and less invasive therapeutic option in this group of patients. Standard ‘long’ DBEs have limitations of long working length and the need for modified ERCP accessories. ‘Short’ DBEs are equally as effective in reaching the target limb as standard ‘long’ DBEs, and overcomes some limitations of long DBEs to result in high success rates for endoscopic therapy.     

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.     

Passive-bending,short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients

AIM:To evaluate short-type-single-balloon enteroscope(SBE) with passive-bending,high-force transmission functions for endoscopic retrograde cholangiopancreatography(ERCP) in patients with Roux-en-Y anastomosis.METHODS:Short-type SBE with this technology(SIF-Y0004-V01; working length,1520 mm; channel diameter,3.2 mm) was used to perform 50 ERCP procedures in 37 patients with Roux-en-Y anastomosis.The rate of reaching the blind end,time required to reach the blind end,diagnostic and therapeutic success rates,and procedure time and complications were studied retrospectively and compared with the results of 34 sessions of ERCP performed using a short-type SBE without this technology(SIF-Y0004; working length,1520 mm; channel diameter,3.2 mm) in 25 patients.RESULTS:The rate of reaching the blind end was 90% with SIF-Y0004-V01 and 91% with SIF-Y0004(P = 0.59).The median time required to reach the papilla was significantly shorter with SIF-Y0004-V01 than with SIF-Y0004(16 min vs 24 min,P = 0.04).The diagnostic success rate was 93% with SIFY0004-V01 and 84% with SIF-Y0004(P = 0.17).The therapeutic success rate was 95% with SIF-Y0004-V01 and 96% with SIF-Y0004(P = 0.68).The median procedure time was 40 min with SIF-Y0004-V01 and 36 min with SIF-Y0004(P = 0.50).The incidence of hyperamylasemia was 6.0% in the SIF-Y0004-V01 group and 14.7% in the SIF-Y0004 group(P = 0.723).The incidence of pancreatitis was 0% in the SIFY0004-V01 group and 5.9% in the SIF-Y0004 group(P > 0.999).The incidence of gastrointestinal perforation was 2.0%(1/50) in the SIF-Y0004-V01 group and 2.9%(1/34) in the SIF-Y0004 group(P > 0.999).CONCLUSION:SIF-Y0004-V01 is useful for ERCP inpatients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.     

Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series

BACKGROUND: ERCP is technically challenging in patients who have had a long-limb Roux-en-Y surgical procedure. The recent introduction of the double-balloon endoscope permits the examination of a much longer segment of the small bowel compared with a standard endoscope and may be used to perform ERCP in these patients. OBJECTIVE: To report successful use of double-balloon ERCP in patients who have had a Roux-en-Y surgical procedure. PATIENTS: Fourteen patients with a history of either Roux-en-Y gastric bypass weight-reduction surgery or Roux-en-Y pancreatobiliary surgery required diagnostic and/or therapeutic pancreatobiliary intervention. DESIGN: Case report. INTERVENTION: Double-balloon ERCP. RESULTS: Fourteen patients underwent a total of 20 ERCPs with the double-balloon endoscopy system. The ampulla was successfully reached in 85% of total cases (100% of patients who have had Roux-en-Y weight reduction surgery), with adequate cannulation of either the biliary or pancreatic duct in 80% (88% of patients for weight reduction). Therapeutic intervention, including stone removal, pancreatobiliary-duct dilation, sphincterotomy, stent placement, and removal of previously placed stents, was performed successfully in 6 cases. The mean age was 47 years old. The mean (+/- standard deviation) total duration of the procedure was 99 +/- 48 minutes. There were no immediate or short-term complications. CONCLUSIONS: The double-balloon endoscopy system permits diagnostic and therapeutic ERCP in patients who have had long-limb surgical procedures. Our experience demonstrated that this procedure is well tolerated, safe, and has a high success rate.     

Endoscopic evaluation of the defunctionalized stomach by using ShapeLock technology (with video)

BACKGROUND: Patients with Roux-en-Y gastric bypass (RYGB) present a unique problem if they require diagnostic or therapeutic interventions for which the pancreatobiliary limb or the defunctionalized stomach must be accessed. Novel shape-locking guides have been reported in the literature to reduce looping during colonoscopy, and a new guide is now available to assist with enteroscopy. OBJECTIVE: To use ShapeLock technology to permit evaluation of the defunctionalized stomach. DESIGN: Observational case series. SETTING: Tertiary-care center. PATIENTS: Nine patients with a history of RYGB referred for repeat endoscopic evaluation after initial enteroscopy failed to reach the excluded stomach. INTERVENTIONS: After achieving appropriate levels of sedation, a standard enteroscope was back-loaded with the ShapeLock enteroscopy guide and was inserted through the mouth. The device was moved through the gastrojejunal (GJ) anastomosis, along the Roux limb, and into the distal pancreatobiliary limb. The device was then locked, which allowed the enteroscope to be advanced to the defunctionalized stomach. RESULTS: The ShapeLock guide was able to be advanced to the excluded stomach and perform a thorough examination of the pancreatobiliary limb in 8 of 9 patients, without complications. In 1 patient, the diameter of the GJ anastomosis prevented passage of the device. CONCLUSIONS: The ShapeLock enteroscopy guide can allow access to the upper-GI tract in patients after RYGB, provided the GJ anastomosis is of adequate diameter. This study suggested that the technique is safe and has the potential to allow therapeutic interventions in the defunctionalized stomach and duodenum, including ERCP.     

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

AIM: To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy.METHODS: Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO₂ insufflations.RESULTS: The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis.CONCLUSION: Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.     

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiography for Roux-en-Y reconstruction patients with papilla of Vater or bilioenteric anastomosis

Objective. Roux-en-Y reconstructions can be divided into intact papilla of Vater and bilioenteric anastomosis (BEA) with respect to endoscopic retrograde cholangiography (ERC). Double-balloon enteroscopy-assisted ERC (DBE-ERC) may produce different results between the two populations but lacks studies. Material and methods. Forty-seven patients with Roux-en-Y anastomosis undergoing 73 procedures of DBE-ERC were enrolled between July 2007 and August 2013. There were 14 patients with intact papilla of Vater (group A) and 33 patients with BEA (group B). The effectiveness of DBE-ERC, including data of reaching the blind end, performance of ERC, results of endoscopic therapies, and follow-up were retrospectively analyzed and compared between the two groups. Results. For reaching the blind end, the success rate was not different between the groups (85.7% vs. 81.8%, p = 0.7), but the mean procedure time was significantly shorter for group A (28 min vs. 52 min, p = 0.01). For ERC, the success rate was not different between the groups (91.7% vs. 96.3%, p = 0.53), but the mean procedure time was significantly longer for group A (28.4 min vs. 4 min, p < 0.001). All endoscopic therapies could be successfully performed in both groups. No group A patients and five (23.8%) group B patients developed recurrent biliary stricture/stones requiring interventions during a mean follow-up period of 26.1 months. Conclusions. DBE-ERC was effective for both populations with biliary disorders. Reaching the blind end was more difficult but ERC was easier for patients with BEA in terms of procedure time rather than success rates.     

Rotational assisted endoscopic retrograde cholangiopancreatography in patients with reconstructive gastrointestinal surgical anatomy

AIM: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography(ERCP) in surgically altered anatomy patients. METHODS: Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy(39 with gastric bypass Roux-en-Y, 2 with Billroth Ⅱ gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42(30.9%), biliary obstruction suggested on imaging: 20 of 42(47.6%), suspected sphincter of Oddi dysfunction: 4 of 42(9.5%), abnormal liver enzymes: 1 of 42(2.4%), ascending cholangitis: 2 of 42(4.8%), and bile leak: 2 of 42(4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS: Successful visualization of the major ampulla was accomplished in 32 of 42 procedures(76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla(81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bileduct was cannulated(92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients(23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients(7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d.CONCLUSION: It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.     

Endoscopic transpancreatic septotomy as a precutting technique for difficult bile duct cannulation

AIM: To evaluate the technique of transpancreatic septotomy(TS) for cannulating inaccessible common bile ducts in endoscopic retrograde cholangiopancreatography(ERCP).METHODS: Between May 2012 and April 2013, 1074 patients were referred to our department for ERCP. We excluded 15 patients with previous Billroth Ⅱ gastrectomy, Roux-en-Y anastomosis, duodenal stenosis, or duodenal papilla tumor. Among 1059 patients who underwent ERCP, there were 163 patients with difficult bile duct cannulation. Pancreatic guidewire or pancreatic duct plastic stent assistance allowed for successful ERCP completion in 94 patients. We retrospectively analyzed clinical data from 69 failed patients(36 transpancreatic septotomies and 33 needle-knife sphincterotomies). RESULTS: Of the 69 patients who underwent precut papillotomy, common bile duct cannulation was successfully achieved in 67. The success rates in the TS and needle knife sphincterotomy(NKS) groups were 97.2%(35/36) and 96.9%(32/33), respectively, which were not significantly different(P 0.05). Complications occurred in 11 cases, including acute pancreatitis(n = 6), bleeding(n = 2), and cholangitis(n = 3). The total frequency of complications in the TS group was lower than that in the NKS group(8.3% vs 24.2%, P 0.05).CONCLUSION: Pancreatic guidewire or pancreatic duct plastic stent assistance improves the success rate of selective bile duct cannulation in ERCP. TS and NKS markedly improve the success rate of selective bile duct cannulation in ERCP. TS precut is safer as compared with NKS.     

Endoscopic Ultrasound-Guided Hepaticogastrostomy: Technical Review and Tips to Prevent Adverse Events

Most patients who require biliary drainage can be treated by endoscopic retrograde cholangiopancreatography (ERCP)-guided procedures. However, ERCP can be challenging in patients with complications, such as malignant duodenal obstruction, or a surgically-altered anatomy, such as a Roux-en-Y anastomosis, which prevent advancement of the duodenoscope into the ampulla of Vater. Recently, endoscopic ultrasound (EUS)-guided biliary drainage via transhepatic or transduodenal approaches has emerged as an alternative means of biliary drainage. Typically, EUS-guided gallbladder drainage or choledochoduodenostomy can be performed via both approaches, as can EUS-guided hepaticogastrostomy (HGS). EUS-HGS, because of its transgastric approach, can be performed in patients with malignant duodenal obstruction. Technical tips for EUS-HGS have reached maturity due to device and technical developments. Although the technical success rates of EUS-HGS are high, the rate of adverse events is not low, with stent migration still being reported despite many preventive efforts. In this review, we described technical tips for EUS-HGS related to bile duct puncture, guidewire insertion, fistula dilation, and stent deployment, along with a literature review. Additionally, we provided technical tips to improve the technical success of EUS-HGS.     

Update in enteroscopy: New devices and new indications

The present review provides an update of the currently available (proto‐) types of device‐assisted enteroscopy (DAE). In recent years, newly designed double‐ and single‐balloon enteroscopes have emerged. They aim to improve insertion depth into the small bowel, and they also allow more efficient endoscopic interventions. Nowadays, almost all conventional endoscopic procedures are feasible using DAE, opening the door to new indications. Recently, more data have become available on pediatric DAE, DAE‐assisted colonoscopy, and DAE in patients with altered anatomy, including DAE‐assisted endoscopic retrograde cholangiopancreatography and direct cholangioscopy. Although new enteroscopes are being developed, few comparative studies are available in order to define which DAE suits best for each indication. It is the duty of the international endoscopy community to set up clinical research projects to provide answers to these open questions.