ERCP in Altered Anatomy
- 47 Downloads
Endoscopic retrograde cholangiopancreatography (ERCP), in the new millennium, is primarily therapeutic. Accurate diagnosis is usually obtained by computer-assisted tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasonography (EUS). ERCP is performed whenever endotherapy is required. At the same time, surgical interventions for malignant disease and weight-loss procedures are on the rise. Both procedures critically alter upper gastrointestinal tract anatomy, while many of them are associated with increased risk of biliopancreatic diseases requiring endotherapy.
ERCP in altered anatomy is significantly more difficult than in normal anatomy. The success rate is lower and the complications higher when compared with ERCP in native anatomy. Each step of the procedure is a difficult obstacle to overcome. The first obstacle is to reach the papilla or the ductal anastomosis. The distance is usually quite longer compared to normal anatomy, while postoperative adhesions may create fixed loops and angulations that hamper endoscope advancement. The endoscopist may use a variety of endoscopes or employ dedicated devices to reach the required duct. The second obstacle is to perform cannulation, sphincterotomy, and all planned interventions. Cannulation as well as sphincterotomy, in the presence of a native papilla, is substantially more challenging especially when the position in front of the papilla is not very stable. In almost all cases, the papilla is reached from the caudal side, and all endotherapy is done in a “reverse” position. This adds to the difficulty of the intervention. Long enteroscopes, which are frequently used, require dedicated, longer, catheters to exit the working channel, but these catheters are not always readily available in all departments. These are some of the difficulties encountered while performing ERCP in a patient with surgically altered upper gastrointestinal anatomy.
This chapter will mainly focus on endoluminal approaches to reach the papilla and perform biliopancreatic interventions. A small portion will be dedicated to EUS-guided and laparoscopy-assisted alternatives to perform endotherapy in patients with altered anatomy.
KeywordsERCP Altered anatomy Gastrectomy Roux-en-Y esophagojejunostomy Roux-en-Y gastric bypass Billroth II Whipple’s procedure Device-assisted ERCP Laparoscopy-assisted ERCP EUS
- 1.House MG, Cameron JL, Schulick RD, Campbell KA, Sauter PK, Coleman J, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg. 2006;243(5):571–6; discussion 6–8. https://doi.org/10.1097/01.sla.0000216285.07069.fc. 00000658-200605000-00001 [pii].CrossRefPubMedPubMedCentralGoogle Scholar
- 4.Schutz SM. Grading the degree of difficulty of ERCP procedures. Gastroenterol Hepatol (N Y). 2011;7(10):674–6.Google Scholar
- 10.Wang F, Xu B, Li Q, Zhang X, Jiang G, Ge X, et al. Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: one single center’s experience. Medicine (Baltimore). 2016;95(52):e5743. https://doi.org/10.1097/MD.0000000000005743. 00005792-201612300-00042 [pii].CrossRefGoogle Scholar
- 11.Kim KH, Kim TN. Endoscopic papillary large balloon dilation for the retrieval of bile duct stones after prior Billroth II gastrectomy. Saudi J Gastroenterol. 2014;20(2):128–33. https://doi.org/10.4103/1319-3767.129478. SaudiJGastroenterol_2014_20_2_128_129478 [pii].CrossRefPubMedPubMedCentralGoogle Scholar
- 12.Wu WG, Mei JW, Zhao MN, Zhang WJ, Gu J, Tao YJ, et al. Use of the conventional side-viewing duodenoscope for successful endoscopic retrograde cholangiopancreatography in postgastrectomy patients. J Clin Gastroenterol. 2016;50(3):244–51. https://doi.org/10.1097/MCG.0000000000000442.CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(7):657–83. https://doi.org/10.1055/s-0042-108641.CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Rondonotti E, Spada C, Adler S, May A, Despott EJ, Koulaouzidis A, et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy. 2018;50(4):423–46. https://doi.org/10.1055/a-0576-0566.CrossRefPubMedGoogle Scholar
- 20.Kawaguchi Y, Yamauchi H, Kida M, Okuwaki K, Iwai T, Uehara K, et al. Failure factors to reach the blind end using a short-type single-balloon enteroscope for ERCP with Roux-en-Y reconstruction: a multicenter retrospective study. Gastroenterol Res Pract. 2019:3536487. https://doi.org/10.1155/2019/3536487.
- 21.Katanuma A, Isayama H. Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy in Japan: questionnaire survey and important discussion points at Endoscopic Forum Japan 2013. Dig Endosc. 2014;26(Suppl 2):109–15. https://doi.org/10.1111/den.12247.CrossRefPubMedGoogle Scholar
- 22.Osoegawa T, Motomura Y, Akahoshi K, Higuchi N, Tanaka Y, Hisano T, et al. Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography. World J Gastroenterol. 2012;18(46):6843–9. https://doi.org/10.3748/wjg.v18.i46.6843.CrossRefPubMedPubMedCentralGoogle Scholar
- 23.Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et al. 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). Gastrointest Endosc. 2013;77(4):593–600. https://doi.org/10.1016/j.gie.2012.10.015. S0016-5107(12)02851-9 [pii].CrossRefPubMedGoogle Scholar
- 24.Shimatani M, Hatanaka H, Kogure H, Tsutsumi K, Kawashima H, Hanada K, et al. Diagnostic and therapeutic endoscopic retrograde cholangiography using a short-type double-balloon endoscope in patients with altered gastrointestinal anatomy: a multicenter prospective study in Japan. Am J Gastroenterol. 2016;111(12):1750–8. https://doi.org/10.1038/ajg.2016.420. ajg2016420 [pii].CrossRefPubMedGoogle Scholar
- 27.Kawamura T, Mandai K, Uno K, Yasuda K. Does single-balloon enteroscopy contribute to successful endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy? ISRN Gastroenterol. 2013;2013:214958. https://doi.org/10.1155/2013/214958.
- 28.Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN. Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc. 2018;87(5):1241–7. https://doi.org/10.1016/j.gie.2017.12.024. S0016-5107(18)30010-5 [pii].CrossRefPubMedGoogle Scholar
- 30.Sharaiha RZ, Kumta NA, Desai AP, DeFilippis EM, Gabr M, Sarkisian AM, et al. Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: predictors of successful outcome in patients who fail endoscopic retrograde cholangiopancreatography. Surg Endosc. 2016;30(12):5500–5. https://doi.org/10.1007/s00464-016-4913-y. 10.1007/s00464-016-4913-y [pii].CrossRefPubMedPubMedCentralGoogle Scholar
- 31.James TW, Fan YC, Baron TH. EUS-guided hepaticoenterostomy as a portal to allow definitive antegrade treatment of benign biliary diseases in patients with surgically altered anatomy. Gastrointest Endosc. 2018;88(3):547–54. https://doi.org/10.1016/j.gie.2018.04.2353. S0016-5107(18)32664-6 [pii].CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Chen YI, Levy MJ, Moreels TG, Hajijeva G, Will U, Artifon EL, et al. An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery. Gastrointest Endosc. 2017;85(1):170–7. https://doi.org/10.1016/j.gie.2016.07.031. S0016-5107(16)30382-0 [pii].CrossRefGoogle Scholar
- 41.Azeem N, Tabibian JH, Baron TH, Orhurhu V, Rosen CB, Petersen BT, et al. Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis. Gastrointest Endosc. 2013;77(4):568–77. https://doi.org/10.1016/j.gie.2012.11.031. S0016-5107(12)02981-1 [pii].CrossRefPubMedGoogle Scholar