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Yamamoto H, Despott EJ, González-Suárez B, Pennazio M, Mönkemüller K. The evolving role of device-assisted enteroscopy: The state of the art as of August 2023. Best Pract Res Clin Gastroenterol 2023; 64-65:101858. [PMID: 37652651 DOI: 10.1016/j.bpg.2023.101858] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Device-assisted enteroscopy (DAE), balloon-assisted enteroscopy (BAE) in particular, has become a routine endoscopic procedure which has revolutionized our approach to small-bowel disease. Evidence demonstrating the efficacy and safety of BAE spans over 22-years of experience, making it an established pillar of minimally invasive care. The robust evidence for BAE's safety and efficacy has now been incorporated into international clinical guidelines, technical reviews, benchmarking performance measures and curricula. The more recently introduced motorized spiral enteroscopy (MSE) which had replaced the previous manual version, abruptly ended its 7-year stint in clinical practice, when it was withdrawn and recalled from the market by its manufacturing company in July 2023, due to several associated serious adverse events (including fatalities). This article, written by the original developer of double-balloon enteroscopy (DBE) and other recognized international experts and pioneers in this field, focuses mainly on the technical aspects, evolving indications, and equipment-related technological advances. Despite the very recent withdrawal of MSE from clinical practice, for completeness, this technology and its technique is still briefly covered here, albeit importantly, along with a short description of reported, associated, serious adverse events which have contributed to its withdrawal/recall from the market and clinical practice.
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Affiliation(s)
- Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Tochigi, Japan.
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, London, UK
| | - Begoña González-Suárez
- Department of Gastroenterology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Marco Pennazio
- University Division of Gastroenterology, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Klaus Mönkemüller
- Division of Gastroenterology "Prof. Carolina Olano", Universidad de La República, Montevideo, Uruguay; Division of Endoscopy, Ameos Teaching University Hospital, Halberstadt, Germany; Department of Gastroenterology, Virginia Tech Carilion School of Medicine, Virginia, USA
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Tokuhara M, Shimatani M, Mitsuyama T, Masuda M, Ito T, Miyamoto S, Fukata N, Miyoshi H, Ikeura T, Takaoka M, Kouda K, Okazaki K. Evaluation of complications after endoscopic retrograde cholangiopancreatography using a short type double balloon endoscope in patients with altered gastrointestinal anatomy: a single-center retrospective study of 1,576 procedures. J Gastroenterol Hepatol 2020; 35:1387-1396. [PMID: 32103516 DOI: 10.1111/jgh.15019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) using balloon-assisted endoscope such as double-balloon endoscope is even effective for patients with surgically altered anatomy. Yet comprehensive studies on complications of ERCP using balloon-assisted endoscope have not been made. We analyzed the characteristics and the causes of complications of ERCP using double-balloon endoscope (DB-ERCP) procedures and aimed to suggest effective managements. METHODS A total of 1576 procedures of DB-ERCP in 714 patients with surgically altered gastrointestinal anatomy in our hospital were evaluated retrospectively using a statistic analysis. RESULTS The overall complication occurrence rate was 5.8%. By type of complications are perforation 3.2%, mucosal laceration 0.5%, hemorrhage 1.0%, pancreatitis 0.6%, respiratory disorder 0.4%, and others 0.2%. By type of surgical reconstruction methods were Roux-en-Y reconstruction with choledocho-jejunal anastomosis 4.2%, Roux-en-Y reconstruction without choledocho-jejunal anastomosis 6.7%, pancreaticoduodenectomy 4.5%, pylorus preserving pancreaticoduodenectomy 4.2%, Billroth II gastrectomy (B-II) 11.6%, and other reconstruction method (others) 7.4%. The contributing factors calculated by a multivariate analysis were B-II (odds ratio: 1.864, 95% confidence interval: 1.001-3.471, P = 0.050) and the presence of naïve papilla (odds ratio: 3.268, 95% confidence interval: 1.426-7.490, P = 0.005). CONCLUSIONS DB-ERCP is a safe method with a total complication rate of 5.8% that could be considered within an acceptable range. The most common complication was the injury of the digestive tract such as perforation. Affecting risk factors for complications were B-II and the presence of naïve papilla. DB-ERCP procedures should be performed carefully of these factors.
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Affiliation(s)
- Mitsuo Tokuhara
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Masaaki Shimatani
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Toshiyuki Mitsuyama
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Masataka Masuda
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Takashi Ito
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Sachi Miyamoto
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Norimasa Fukata
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Hideaki Miyoshi
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Makoto Takaoka
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Katsuyasu Kouda
- Department of Hygiene and Public Health, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Kazuichi Okazaki
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University Hirakata Hospital, Osaka, Japan
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Uchida D, Tsutsumi K, Kato H, Matsumi A, Saragai Y, Tomoda T, Matsumoto K, Horiguchi S, Okada H. Potential Factors Affecting Results of Short-Type Double-Balloon Endoscope-Assisted Endoscopic Retrograde Cholangiopancreatography. Dig Dis Sci 2020; 65:1460-1470. [PMID: 31562611 DOI: 10.1007/s10620-019-05857-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/18/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Short-type double-balloon endoscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) has been developed as an alternative approach for cases with a surgically altered gastrointestinal anatomy. However, this technique is sometimes technically challenging and carries a risk of severe adverse events. AIMS To evaluate the factors affecting the technical success rate and adverse events of DBE-ERCP. METHODS A total of 319 patients (805 procedures) with a surgically altered gastrointestinal anatomy underwent short DBE-ERCP. The factors affecting the technical success rate and adverse events, and the learning curve of the trainees were retrospectively evaluated. RESULTS The technical success rate of all procedures was 90.7%. Adverse events occurred in 44 (5.5%) procedures. A multivariate analysis indicated that Roux-en-Y reconstruction and first-time short DBE-ERCP were factors affecting the technical failure and adverse event rates, while the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction was a non-risk factor for adverse events. The trainee caseload did not affect the technical success or adverse event rates significantly; however, trainees tended to perform cases involving the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction. The success rate of scope insertion increased according to experience; however, the overall success rate did not differ to a statistically significant extent. CONCLUSION Short DBE-ERCP was useful and safe for managing cases with a surgically altered anatomy; however, trainees should concentrate on accumulating experience with easy cases, such as those with the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction or a history of DBE-ERCP.
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Affiliation(s)
- Daisuke Uchida
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan.
| | - Koichiro Tsutsumi
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Hironari Kato
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Akihiro Matsumi
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yosuke Saragai
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Shigeru Horiguchi
- Department of General Medicine, Okayama University Hospital, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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Double balloon enteroscopy improves ERCP success in patients with modified small bowel anatomy. North Clin Istanb 2020; 7:131-139. [PMID: 32259034 PMCID: PMC7117630 DOI: 10.14744/nci.2020.54533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/21/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE: The aim of this study was to evaluate the effect of double-balloon enteroscopy (DBE) on the success of endoscopic retrograde cholangiopancreatography (ERCP) procedures in patients with surgically modified gastrointestinal (GI) tract anatomy. METHODS: The medical records of patients who underwent ERCP in the Gastroenterology Department of Kocaeli University School of Medicine hospital between December 2008 and September 2014 were examined. From the patient group that was scheduled to undergo DBE-ERCP, the details of cases in which ERCP via standard duodenoscope or DBE-ERCP was performed during the same session because standard ERCP failed were included. Procedure parameters, outcomes, and complications related to the procedure in both groups were analyzed. Patients who underwent the DBE-ERCP procedure directly, those who underwent push enteroscopy, or gastroscopy to evaluate the GI tract anatomy before the day of ERCP, and who underwent DBE-ERCP on a day other than the initial ERCP session were excluded. Afferent loop intubation, access to the major papilla, selective cannulation, therapeutic success rates, and the effect of DBE on overall procedure success were evaluated. RESULTS: Fifty-one patients with a history of BII gastrojejunostomy and 11 patients with hepaticojejunostomy (with or without Roux-en-Y) were included in the study. In all patients, the ERCP procedure was initiated with a standard duodenoscope. If intubation of the afferent loop was unsuccessful in reaching the major papilla or enterobiliary anastomosis, DBE was used. In 30 (48.4%) of the 62 patients whose GI tract was anatomically altered, the duodenoscope was successfully advanced to the ampulla and 27 (43.5%) were cannulated successfully. Thirty-one patients underwent DBE-ERCP. DBE reached the ampulla or enterobiliary anastomosis in 30 patients (96.8%) and selective choledocus cannulation was achieved in all patients but 3 (90%), including 1 patient with a hepaticojejunostomy. The overall ERCP success rate increased from 43.5% (27/62) to 87.1% (54/62). Two perforations (1 during standard duodenoscopy and 1 with DBE-ERCP) were observed. CONCLUSION: The overall success rate of ERCP increased with use of the DBE technique in patients with small bowel anatomic variations that were the result of previous surgery.
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Sano I, Katanuma A, Kuwatani M, Kawakami H, Kato H, Itoi T, Ono M, Irisawa A, Okabe Y, Iwashita T, Yasuda I, Ryozawa S, Kaino S, Sakamoto N. Long-term outcomes after therapeutic endoscopic retrograde cholangiopancreatography using balloon-assisted enteroscopy for anastomotic stenosis of choledochojejunostomy/pancreaticojejunostomy. J Gastroenterol Hepatol 2019; 34:612-619. [PMID: 30650206 DOI: 10.1111/jgh.14605] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 01/06/2019] [Accepted: 01/09/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Data on long-term outcomes after therapeutic endoscopic retrograde cholangiopancreatography (ERCP) using balloon-assisted enteroscopy (BAE) for choledochojejunal anastomotic stenosis (CJS) or pancreaticojejunal anastomotic stenosis (PJS) remain limited. We retrospectively assessed the long-term results of patients who achieved clinical success using BAE for CJS and PJS. METHODS Patients who achieved technical and clinical success for CJS or PJS by BAE-ERCP and were followed up for more than 6 months after the initial BAE-ERCP therapy were retrospectively identified at 11 Japanese institutions. The primary end-point was CJS or PJS recurrence rates. The secondary end-points were initial therapy details, initial therapy complications, and CJS or PJS recurrence treatment details. We also evaluated restenosis-associated factors. RESULTS From September 2008 to December 2015, 67 patients (CJS, 61; PJS, six) were included. The overall CJS and PJS recurrence rates were 34.4% and 33.3%, respectively. The 1-year CJS recurrence rate was 18.5% (95% confidence interval, 10.7-31.0). Of all the patients, 88.1% underwent balloon dilation at the anastomotic stenosis site; stent placement was performed in 15 of 67 patients (22.4%). The complication rate was 8.2% in CJS and 0% in PJS. In patients who underwent balloon dilation, "remaining waist" was significantly associated with CJS recurrence after anastomotic balloon dilation (P = 0.001). CONCLUSIONS The long-term outcomes of BAE-ERCP were comparable with those of percutaneous transhepatic treatment or surgical re-anastomosis.
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Affiliation(s)
- Itsuki Sano
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University, Okayama, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Michihiro Ono
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Seiji Kaino
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
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Yamada A, Kogure H, Nakai Y, Takahara N, Mizuno S, Tada M, Koike K. Performance of a new short-type double-balloon endoscope with advanced force transmission and adaptive bending for pancreaticobiliary intervention in patients with surgically altered anatomy: A propensity-matched analysis. Dig Endosc 2019; 31:86-93. [PMID: 30151924 DOI: 10.1111/den.13261] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM A new short-type double-balloon endoscope (DBE) has been developed with a major focus on facilitating scope insertion to the target site for pancreaticobiliary interventions in patients with surgically altered anatomy. We investigated the performance of this new short-type DBE by comparing it with a conventional DBE. METHODS Data from 885 endoscopic retrograde cholangiopancreatography (ERCP) procedures using balloon endoscopy were analyzed. We used propensity score matching to adjust for differences between patients who underwent ERCP procedures using the new short-type DBE versus the conventional short-type DBE. RESULTS A total of 163 pairs of patients were selected by propensity score matching. Success rate of reaching the target site was 100% in both the new DBE group and the conventional DBE group (P = 1.0). The new DBE group had a shorter insertion time required to reach the target site than the conventional DBE group (10 min vs. 14 min, P < 0.01). Success rate of pancreaticobiliary interventions in the new DBE group was as high as that in the conventional DBE group (92% vs. 89% P = 0.35). Overall procedure time decreased from 62 min in the conventional DBE group to 55 min in the new DBE group (P = 0.26). No significant differences in the rates of adverse events were observed between the two groups. CONCLUSION A new short-type DBE allows faster insertion to the target site for pancreaticobiliary intervention in patients with surgically altered anatomy.
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Affiliation(s)
- Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Shimatani M, Tokuhara M, Kato K, Miyamoto S, Masuda M, Sakao M, Fukata N, Miyoshi H, Ikeura T, Takaoka M, Okazaki K. Utility of newly developed short-type double-balloon endoscopy for endoscopic retrograde cholangiography in postoperative patients. J Gastroenterol Hepatol 2017; 32:1348-1354. [PMID: 28019036 DOI: 10.1111/jgh.13713] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/16/2016] [Accepted: 12/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The utility of conventional short-type double-balloon endoscopy (DBE) for pancreatobiliary disease in patients with postoperative anatomy had been widely acknowledged and accepted. However, some technical difficulties yet remained. In an attempt to solve these problems, the new short-type DBE (N-short DBE) was uniquely designed for therapeutic endoscopic retrograde cholangiography (ERC) in postoperative patients. The aim of this study was to evaluate the usefulness of N-short DBE for ERC in postoperative patients. METHODS From August 2015 to April 2016, ERC using N-short DBE (DB-ERC) was performed in 100 postoperative patients (112 procedures). We retrospectively studied the success rate of reaching the blind end, the median time to reach the blind end, the diagnostic success rate, the therapeutic success rate, the median time to complete ERC-related interventions, the overall success rate, the median time to complete DB-ERC, and adverse events. RESULTS The success rate of reaching the blind end was 99.1%. The median time to reach the blind end was 10 min (interquartile range [IQR], 6-19 min). The diagnostic success rate was 98.2%. The therapeutic success rate was 100%. The median time to complete ERC-related interventions was 36 min (IQR, 22-62 min). The overall DB-ERC success rate was 97.3%. The median time to complete DB-ERC was 54 min (IQR, 37-73 min). The occurrence of adverse events was 2.7%. CONCLUSIONS The N-short DBE for ERC in postoperative patients is useful and safe. DB-ERC is promising therapeutic modality in such patients and should be selected as the first-line policy.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Mitsuo Tokuhara
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Kota Kato
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Sachi Miyamoto
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Masataka Masuda
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Masayuki Sakao
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Norimasa Fukata
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Hideaki Miyoshi
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Makoto Takaoka
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Kazuichi Okazaki
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
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Management of biliary anastomotic strictures after liver transplantation. Transplant Rev (Orlando) 2017; 31:207-217. [DOI: 10.1016/j.trre.2017.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/06/2017] [Accepted: 03/19/2017] [Indexed: 12/13/2022]
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Shao XD, Qi XS, Guo XZ. Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: A meta-analysis. Saudi J Gastroenterol 2017; 23:150-160. [PMID: 28611338 PMCID: PMC5470374 DOI: 10.4103/1319-3767.207713] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to evaluate the effectiveness and safety of endoscopic retrograde cholangiopancreatography with double balloon enteroscope (DBE-ERCP) in patients with altered gastrointestinal anatomy in a meta-analysis. MATERIALS AND METHODS A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane library covering the period from January 2001 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using the I2 test. RESULTS Ten studies involving a total of 301 patients were included in the analysis. The pooled enteroscopy, diagnostic, and therapeutic success rates were 89.75% [95% confidence interval (CI): 79.65-94.30%], 79.92% (95% CI: 68.06-89.59%), and 63.55% (95% CI: 53.70-72.86%), respectively. DBE-ERCP-related complications occurred in 18 patients including perforation (5), pancreatitis (3), cholangitis (9), and bleeding (1). The incidence of DBE-ERCP-related complication was 6.27% (95% CI: 2.61-11.38%). CONCLUSION Diagnostic and therapeutic DBE-ERCPs are feasible in patients with altered gastrointestinal anatomy. DBE-ERCP may be considered when pancreaticobiliary diseases occur in patients undergoing Roux-en-Y reconstruction or pancreaticoduodenectomy.
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Affiliation(s)
- Xiao-Dong Shao
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China,Address for correspondence: Dr. Xiao-Dong Shao, Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang - 110016, China. E-mail:
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China
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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; 111:1750-1758. [PMID: 27670601 DOI: 10.1038/ajg.2016.420] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/19/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the utility and safety of a short-type double-balloon endoscope (DBE) in the treatment of biliary disease in patients with surgically altered gastrointestinal (GI) anatomy. METHODS This study was conducted as a multicenter, single-arm, prospective trial at five tertiary academic care centers and three community-based hospitals in Japan. Consecutive patients with biliary disease with altered GI anatomy were prospectively included in this study. RESULTS A total of 311 patients underwent double-balloon endoscopic retrograde cholangiography (ERC). The success rate of reaching the target site, the primary end point, was 97.7% (95% confidence interval (CI): 95.4-99.1). The success rate of biliary cannulation and contrast injection of the targeted duct, the secondary end point, was 96.4% (95% CI: 93.6-98.2), and the therapeutic success rate was 97.9% (95% CI: 95.4-99.2). Adverse events occurred in 33 patients (10.6%, 95% CI: 7.1-14.0) and were managed conservatively in all patients with the exception of 1 in whom a perforation developed, requiring emergency surgery. CONCLUSIONS ERC using a short-type DBE resulted in an excellent therapeutic success rate and a low rate of adverse events. This treatment can be a first-line treatment for biliary disease in patients with surgically altered GI anatomy.
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Inamdar S, Slattery E, Sejpal DV, Miller LS, Pleskow DK, Berzin TM, Trindade AJ. Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc 2015; 82:9-19. [PMID: 25922248 DOI: 10.1016/j.gie.2015.02.013] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/07/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgically altered pancreaticobiliary anatomy increases the difficulty of performing ERCP. Single-balloon enteroscopy (SBE) is a relatively new technique that can be used for ERCP in patients with surgically altered anatomy. OBJECTIVE To evaluate the therapeutic and diagnostic success of SBE-ERCP among patients with surgically altered anatomy. DESIGN/SETTING Systematic review and meta-analysis of studies involving SBE-ERCP in patients with Roux-en-Y gastric bypass, hepaticojejunostomy, or Whipple procedure. Enteroscopy success was defined as success in reaching the papilla and/or biliary anastomosis by using SBE. Diagnostic success was defined as obtaining a cholangiogram. Procedural success was defined as the ability to provide successful intervention, if appropriate. A random-effects model was used. RESULTS A total of 461 patients underwent SBE-ERCP from 15 trials. The pooled enteroscopy, diagnostic, and procedural success rates were 80.9% (95% confidence interval [CI], 75.3%-86.4%), 69.4% (95% CI, 61.0%-77.9%), and 61.7% (95% CI, 52.9%-70.5%), respectively. There was statistical large heterogeneity for enteroscopy, diagnostic, and therapeutic success (P < .001 for all). Adverse events occurred in 6.5% (95% CI, 4.7%-9.1%) of patients. There was no evidence of publication bias in this meta-analysis. LIMITATIONS Our findings and interpretations are limited by the quantity and heterogeneity of the studies included in the analysis. CONCLUSION SBE-ERCP has high diagnostic and procedural success rates in this challenging patient population. It should be considered a first-line intervention when biliary access is required after Roux-en-Y gastric bypass, hepaticojejunostomy, or Whipple procedure.
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Affiliation(s)
- Sumant Inamdar
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA
| | - Eoin Slattery
- Department of Preventive Medicine and Nutrition, Columbia University Medical Center, New York, New York, USA
| | - Divyesh V Sejpal
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA
| | - Larry S Miller
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA
| | - Douglas K Pleskow
- The Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tyler M Berzin
- The Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Arvind J Trindade
- Department of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York, USA; The Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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12
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Shimatani M, Takaoka M, Tokuhara M, Miyoshi H, Ikeura T, Okazaki K. Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy. World J Gastrointest Endosc 2015; 7:617-627. [PMID: 26078830 PMCID: PMC4461936 DOI: 10.4253/wjge.v7.i6.617] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 01/14/2015] [Accepted: 03/09/2015] [Indexed: 02/05/2023] Open
Abstract
The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.
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Oana S, Shibata S, Matsuda N, Matsumoto T. Efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stone removal. Dig Liver Dis 2015; 47:401-4. [PMID: 25769504 DOI: 10.1016/j.dld.2015.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 02/05/2015] [Accepted: 02/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography is difficult to perform in patients with gastrointestinal tract reconstruction. AIMS To evaluate the efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stones in patients with gastrointestinal tract reconstruction. METHODS We conducted a retrospective case series with a comparison to historical controls. During the period 2009-2013, 11 postoperative patients underwent endoscopic papillary large-balloon dilatation (Group A). Procedure efficacy and safety were compared with patients who underwent endoscopic sphincterotomy without endoscopic papillary large-balloon dilatation, who served as historical controls (Group B). RESULTS Group A consisted of 11 patients (63.6% males, mean age 78±10 years), and Group B consisted of 32 patients (78.1% males, mean age 75±7 years). The stone clearance rate was significantly higher in Group A than in Group B (100% vs. 65.6%, respectively; p<0.05). Median procedure time was significantly shorter in Group A than in Group B (54min vs. 102min, respectively; p<0.05), and the complication rate was not significantly different between groups (18% vs. 15.6%, respectively; p=0.586). CONCLUSION Endoscopic papillary large-balloon dilatation may be an effective and safe treatment procedure in patients with gastrointestinal tract reconstruction.
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Affiliation(s)
- Shuhei Oana
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Japan.
| | - Sho Shibata
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Japan
| | - Nozomi Matsuda
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Japan
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14
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Yamauchi H, Kida M, Okuwaki K, Miyazawa S, Iwai T, Tokunaga S, Takezawa M, Imaizumi H, Koizumi W. Passive-bending, short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients. World J Gastroenterol 2015; 21:1546-1553. [PMID: 25663773 PMCID: PMC4316096 DOI: 10.3748/wjg.v21.i5.1546] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/29/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
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 SIF-Y0004-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 SIF-Y0004-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 in patients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.
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Hatanaka H, Yano T, Tamada K. Tips and tricks of double-balloon endoscopic retrograde cholangiopancreatography (with video). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:E28-34. [DOI: 10.1002/jhbp.218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 12/19/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Hisashi Hatanaka
- Department of Gastroenterology; Jichi Medical University; 3311-1 Yakushiji Shimotsuke Tochigi 329-0498 Japan
| | - Tomonori Yano
- Department of Gastroenterology; Jichi Medical University; 3311-1 Yakushiji Shimotsuke Tochigi 329-0498 Japan
| | - Kiichi Tamada
- Department of Gastroenterology; Jichi Medical University; 3311-1 Yakushiji Shimotsuke Tochigi 329-0498 Japan
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16
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Shimatani M, Fukata N, Suzuki R, Miyamoto S, Kato K, Mitsuyama T, Miyoshi H, Ikeura T, Takaoka M, Okazaki K. Small bowel intervention and application of enteroscopy for altered small bowel anatomy—endoscopic advanced therapy using double balloon enteroscopy. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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17
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Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc 2014; 29:1753-9. [DOI: 10.1007/s00464-014-3901-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 09/12/2014] [Indexed: 01/26/2023]
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18
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Itoi T, Sofuni A, Tsuchiya T, Ijima M, Iwashita T. Endoscopic ultrasonography-guided transhepatic antegrade stone removal in patients with surgically altered anatomy: case series and technical review (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:E86-93. [PMID: 25231935 DOI: 10.1002/jhbp.165] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Recently, endoscopic ultrasonography (EUS)-guided transhepatic antegrade interventions have been introduced in patients with a surgically altered anatomy. Herein, we focused on and reviewed EUS-guided transhepatic antegrade stone removal (EUS-TASR) in patients with a surgically altered anatomy and native papilla. The basic technique of EUS-TASR involves the following steps: (1) EUS-guided needle puncture; (2) guidewire placement; (3) tract dilation; (4) balloon sphincteroplasty; (5) stone removal; and (6) stent placement if needed. Based on reports in the literature including our cases, the complete stone extraction rate is 71.4% (10/14) including five of our cases (60% success rate) at one session without serious complications. In conclusion, EUS-TASR appears to be feasible and useful in selected patients although its application may be limited depending on anatomical factors and current devices used.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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19
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Unusual bleeding from hepaticojejunostomy controlled by adult variable stiffness colonoscopy: report of a case and literature review. Int Surg 2014; 99:584-9. [PMID: 25216425 DOI: 10.9738/intsurg-d-13-00126.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We herein present a case of a 59-year-old man who had undergone pylorus preserving pancreaticoduodenectomy with regional lymph node dissection prior to episodes of melena. Series of conventional endoscopic investigations failed to identify the bleeding source. Enhanced computed tomography scan revealed complete obstruction of the main portal vein with numerous collateral veins running towards the hepatic hilus. Comprehensively, hemorrhage from the jejunal varices caused by postoperative portal hypertension was highly suspected. As the jejunal loop was out of reach, adult variable-stiffness colonoscope (AVSC) was utilized to solve the Roux-en-Y anatomy. Numerous telangiectasis and small varices at hepaticojejunostomy were observed and in the mean time, bleeding was noticed and endoclips were placed without any delay. Ectopic variceal bleeding in jejunal loop after pancreaticoduodenectomy is difficult to manage. We believe that AVSC is an alternative device when specialized jejunal endoscopy is not available.
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Lenze F, Meister T, Matern P, Heinzow HS, Domschke W, Ullerich H. Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography in patients with surgically altered anatomy: higher failure rate in malignant biliary obstruction - a prospective single center cohort analysis. Scand J Gastroenterol 2014; 49:766-71. [PMID: 24694357 DOI: 10.3109/00365521.2014.904397] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The performance of endoscopic retrograde cholangiopancreaticography (ERCP) in patients with post-surgically altered anatomy is technically ambitious. Our study aimed at comparing a cohort of patients having successfully undergone single-balloon enteroscopy (SBE)-assisted ERCP to those in whom SBE-ERCP failed. METHODS This trial is a prospective single center cohort study. Participants included 30 patients (median age 69.5 years, range 20-86 years) with previous pancreaticobiliary surgery. First, a conventional ERCP approach was attempted in all patients. Additionally, those patients in whom prior conventional ERCP had failed underwent SBE-ERCP (n = 26). Patients' baseline characteristics were retrieved and patient cohorts with and without successful SBE-ERCPs were compared and analyzed. Statistical analysis was applied. Univariate analysis was performed to detect possible risk factors of SBE-ERCP failure. RESULTS The overall success rate of SBE-ERCP, including two patients with percutaneous transhepatic cholangiography- assisted rendezvous technique was 65.4% (17/26). Patients with malignant obstructive cholestasis had a significantly higher failure rate compared to those with benign strictures (84.2% vs. 14.2%, p < 0.001). DISCUSSION SBE-ERCP is a promising tool for diagnostic and therapeutic procedures in the pancreaticobiliary system of selected, previously operated patients with failure of conventional ERCP. However, higher failure rates in malignant biliary obstruction should be taken into account.
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Affiliation(s)
- Frank Lenze
- Department of Medicine B, University of Muenster , Muenster , Germany
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21
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Shimatani M, Takaoka M, Ikeura T, Mitsuyama T, Okazaki K. Evaluation of endoscopic retrograde cholangiopancreatography using a newly developed short-type single-balloon endoscope in patients with altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 2:147-55. [PMID: 24750166 DOI: 10.1111/den.12283] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 02/13/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy had been impractical until the development of balloon-assisted endoscope (BAE) made it feasible. The aim of the present study was to evaluate the usefulness of a newly developed short-type single-balloon endoscope (s-SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal anatomy. METHODS From March 2013 to November 2013, s-SBE-assisted ERCP was done in our hospital in 26 postoperative patients who had surgically altered anatomy. We retrospectively evaluated the success rate of reaching the blind end, the mean time required to reach the blind end, the diagnostic success rate, the therapeutic success rate, the mean procedure time, and complications. RESULTS The success rate of reaching the blind end was 92.3%. The mean time required to reach the blind end was 25.3 min. The diagnostic success rate was 91.7%. The diagnostic success rate for naïve papilla was 75%. The mean procedure time was 56.0 min. The success rate of overall s-SBE-assisted ERCP was 84.6%. The complication rate was 3.8%. CONCLUSION Diagnostic and therapeutic ERCP using a newly developed s-SBE is sufficiently effective.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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22
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Itokawa F, Itoi T, Ishii K, Sofuni A, Moriyasu F. Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection. Dig Endosc 2014; 26 Suppl 2:136-43. [PMID: 24750164 DOI: 10.1111/den.12254] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/17/2014] [Indexed: 12/17/2022]
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.
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Affiliation(s)
- Fumihide Itokawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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23
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Kato H, Tsutsumi K, Harada R, Okada H, Yamamoto K. Short double-balloon enteroscopy is feasible and effective for endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 2:130-5. [PMID: 24750163 DOI: 10.1111/den.12251] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/12/2014] [Indexed: 12/14/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) for patients with digestive tract reconstruction is a difficult procedure from an anatomical point of view. A short-type double-balloon enteroscope has a 2.8-mm working channel and a 152-cm working length, and its advantage is that it can accommodate most conventional devices for ERCP. Although the shorter length compared with the long-type balloon-assisted enteroscope (BAE) was suspected of making it difficult or impossible to reach the blind end, in fact, the success rate of reaching the blind end with the short type is similar to that with the long- type BAE. In addition, the success rate of ERCP-related procedures with the short type is satisfactory. However, it remains controversial as to which BAE is more suitable for this procedure. Further randomized controlled trials by high-volume centers are warranted.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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24
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Tomizawa Y, Sullivan CT, Gelrud A. Single balloon enteroscopy (SBE) assisted therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with roux-en-y anastomosis. Dig Dis Sci 2014; 59:465-70. [PMID: 24185681 DOI: 10.1007/s10620-013-2916-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/05/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis is a complex challenge. Long length of afferent limb after an acute angle at the jejunojejunostomy and altered location of the biliary orifice make biliary cannulation difficult. Single balloon enteroscopy assisted ERCP (SBE-ERCP) is a promising alternative to conventional approaches. AIM The purpose of this study was to assess the efficacy and safety of SBE-ERCP in patients with Roux-en-Y reconstruction at a high volume tertiary referral center. METHODS This is a retrospective cohort study. All procedures were performed by a single, experienced pancreatobiliary endoscopist. Patient demographics and related clinical data were obtained. The rate of procedure successes and complications were determined. RESULTS Fourteen patients (nine women) with a median age of 63 years (range 35-83 years) underwent 22 SBE-ERCP procedures from March 2009 to May 2011. Surgically altered anatomy consisted of Whipple procedure (n = 4), hepaticojejunostomy (n = 9) and partial gastrectomy (n = 1). Indications for SBE-ERCP were obstructive jaundice (n = 10), cholangitis (n = 7), post-PTC internalization (n = 3) and biliary stent extraction/exchange (n = 2). The hepaticojejunostomy site (HJS) was reached in 15 (68 %) procedures. Successful interventions were performed in 11 (73 %) of 15 cases, including balloon dilation of biliary strictures (n = 3), insertion of biliary stents (n = 7), retrieval of biliopancreatic stents (n = 4) and biliary stone extraction (n = 4). The mean procedural time for successful interventions was 97.6 min (range 73-147 min). No procedural complications occurred during the median follow-up of 501 days (range 22-1,242 days). CONCLUSION SBE-ERCP is safe and carries an acceptable success rate in experienced hands.
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Affiliation(s)
- Yutaka Tomizawa
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Shimatani M, Takaoka M, Matsushita M, Okazaki K. Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 1:70-8. [PMID: 24118126 DOI: 10.1111/den.12175] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/16/2013] [Indexed: 12/11/2022]
Abstract
Endoscopic treatment for pancreatobiliary diseases is less invasive than surgery and percutaneous transhepatic biliary drainage is highly beneficial to patients. The endoscopic approach is indicated for an increasing number of patients, including those who have undergone previous gastrointestinal surgery, although these patients face two major challenges. First, the endoscopic approach to the afferent loop, blind end, and the site of choledochojejunostomy is difficult with the use of a conventional endoscope because of the distance from the gastrojejunal anastomosis site, unusual anatomical features of the intestine such as its winding shape, and postoperative adhesion. Second, it is difficult to reach Vater's papilla or the site of choledochojejunostomy and to cannulate selectively into the pancreatic and/or biliary duct. The balloon-assisted endoscope (BAE), a recently developed technology, can be useful for carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. ERCP using the BAE is highly effective and safe in patients with altered gastrointestinal anatomy, especially in patients with Roux-en-Y reconstruction.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
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Shimatani M, Takaoka M, Okazaki K. Tips for double balloon enteroscopy in patients with Roux-en-Y reconstruction and modified child surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:E22-8. [PMID: 24307491 DOI: 10.1002/jhbp.53] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pancreatobiliary disease in patients with altered anatomic intestine is one of the most difficult cases for pancreatobiliary endoscopic therapies and diagnosis. There are two major challenges to overcome to complete the procedure. The first challenge is the deep insertion to the blind end. The second challenge is the endoscopic retrograde cholangiopancreatography (ERCP)-related intervention. Impairing either success means the incompletion of the procedure. The double balloon enteroscope (DBE), which has been recently developed, enabled the deep intubation to the blind end. Especially, using the scopes with a short working length allowed us to perform the ERCP-related interventions with a high success rate. Generally, ERCP using double balloon endoscope (DB-ERCP) in patients with altered gastrointestinal anatomy has been established. We introduce our standard technique for DB-ERCP and provide several tips for insuring a successful procedure.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.
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27
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Mönkemüller K, McGuire B, Wilcox CM, Ramesh J, DuBay D, Eckhoff D. Percutaneous balloon dilation and placement of endoscopic biliary stent by using the double-balloon enteroscopy ERCP rendezvous technique. Gastrointest Endosc 2013; 78:383-5. [PMID: 23867379 DOI: 10.1016/j.gie.2013.03.1322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 03/13/2013] [Indexed: 02/08/2023]
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Namikawa T, Munekage E, Kitagawa H, Okabayashi T, Kobayashi M, Hanazaki K. Double tract reconstruction after gastrectomy facilitates endoscopic access to the biliary tree. Dig Dis Sci 2013. [PMID: 23192648 DOI: 10.1007/s10620-012-2498-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
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Azeem N, Tabibian JH, Baron TH, Orhurhu V, Rosen CB, Petersen BT, Gostout CJ, Topazian MD, Levy MJ. 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; 77:568-77. [PMID: 23369652 DOI: 10.1016/j.gie.2012.11.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 11/23/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiography (ERC) is technically challenging in liver transplant patients with Roux-en-Y biliary anastomosis. The optimal endoscope for such cases remains unknown. OBJECTIVE Compare efficacy and safety of performing ERC in liver transplant patients with Roux-en-Y biliary anastomosis by using an adult colonoscope (AC), a pediatric colonoscope (PC), and a single-balloon enteroscope (SBE). DESIGN Retrospective chart review. SETTING Tertiary-care referral center. PATIENTS Liver transplant patients with Roux-en-Y biliary anastomoses. INTERVENTION ERC with AC, PC, and SBE. MAIN OUTCOME MEASUREMENTS Rates of reaching the afferent limb and biliary anastomosis; rates of cannulation; rates of diagnostic, therapeutic, and procedural success; and number of adverse events. RESULTS Ninety patients underwent 199 ERCs from 2002 to 2012; 86 with an AC, 55 with a PC, and 58 with an SBE. Biliary cannulation and diagnostic, therapeutic, and procedural success rates were all significantly higher with an SBE than with a PC. Among patients undergoing the initial ERC, no statistical difference was found among SBE, the PC, and an AC. However, the rate of procedural success with SBE during initial ERC over the last 4 years has increased. Of 25 total failures with ACs, exchange for SBEs resulted in procedural success in 4 of 4 attempts. Of 22 failures with a PC, exchange for an SBE resulted in success in 3 of 4 cases. Of 4 failures with SBE exchange in 6 cases (4 to AC, 2 to PC), SBE resulted in success in only 1. No adverse events occurred directly related to type of endoscope. LIMITATIONS Retrospective study, single center, lack of standardized approach to selection of endoscopes, uncontrolled variables (general anesthesia, learning curve). CONCLUSION In liver transplant patients with Roux-en-Y anatomy, rates of biliary cannulation, therapeutic success, and procedural success are higher with use of an SBE than with a PC and tend to be higher compared with use of an AC among the overall cohort. Use of an SBE and procedural success rates with SBEs have increased over the last 4 years. Failed cases with either an AC or PC can be completed if exchanged for an SBE.
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Affiliation(s)
- Nabeel Azeem
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Yamauchi H, Kida M, Okuwaki K, Miyazawa S, Iwai T, Takezawa M, Kikuchi H, Watanabe M, Imaizumi H, Koizumi W. Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy. World J Gastroenterol 2013; 19:1728-35. [PMID: 23555161 PMCID: PMC3607749 DOI: 10.3748/wjg.v19.i11.1728] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Revised: 12/17/2012] [Accepted: 12/22/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effectiveness of a short-type single-balloon-enteroscope (SBE) for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a reconstructed intestine. METHODS Short-type SBE was developed to perform ERCP in postoperative patients with a reconstructed intestine. Short-type SBE is a direct-viewing endoscope with the following specifications: working length, 1520 mm; total length, 1840 mm; channel diameter, 3.2 mm. In addition, short-type SBE has a water-jet channel. The study group comprised 22 patients who underwent 31 sessions of short-type SBE-assisted ERCP from June 2011 through May 2012. Reconstruction was performed by Billroth-II (B-II) gastrectomy in 6 patients (8 sessions), Roux-en-Y (R-Y) gastrectomy in 14 patients (21 sessions), and R-Y hepaticojejunostomy in 2 patients (2 sessions). We retrospectively studied the rate of reaching the blind end (papilla of Vater or choledochojejunal anastomosis), mean time required to reach the blind end, diagnostic success rate (defined as the rate of successfully imaging the bile and pancreatic ducts), therapeutic success rate (defined as the rate of successfully completing endoscopic treatment), mean procedure time, and complications. RESULTS Among the 31 sessions of ERCP, the rate of reaching the blind end was 88% in B-II gastrectomy, 91% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The mean time required to reach the papilla was 18.3 min in B-II gastrectomy, 21.1 min in R-Y gastrectomy, and 32.5 min in R-Y hepaticojejunostomy. The diagnostic success rates in all patients and those with an intact papilla were respectively 86% and 86% in B-II gastrectomy, 90% and 87% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. The therapeutic success rates in all patients and those with an intact papilla were respectively 100% and 100% in B-II gastrectomy, 94% and 92% in R-Y gastrectomy, and 100% in R-Y hepaticojejunostomy. Because the channel diameter was 3.2 mm, stone extraction could be performed with a wire-guided basket in 12 sessions, and wire-guided intraductal ultrasonography could be performed in 8 sessions. As for complications, hyperamylasemia (defined as a rise in serum amylase levels to more than 3 times the upper limit of normal) occurred in 1 patient (7 sessions) with a B-II gastrectomy and 4 patients (19 sessions) with an R-Y gastrectomy. After ERCP in patients with an R-Y gastrectomy, 2 patients (19 sessions) had pancreatitis, 1 patient (21 sessions) had gastrointestinal perforation, and 1 patient (19 sessions) had papillary bleeding. Pancreatitis and bleeding were both mild. Gastrointestinal perforation improved after conservative treatment. CONCLUSION Short-type SBE is effective for ERCP in patients with a reconstructed intestine and allows most conventional ERCP devices to be used.
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Costa-Genzini A, Takahashi W, Dos Santos RG, Gaboardi MTCO, Noujaim HM, Yamashita ET, Perosa M, Genzini T. Single-balloon enteroscopy for treating Roux-en-Y choledochojejunostomy stenosis after liver transplantation: a case report. Transplant Proc 2013; 44:2503-4. [PMID: 23026631 DOI: 10.1016/j.transproceed.2012.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Endoscopic treatment of biliary tract complications after Roux-en-Y surgery is still a challenge. With balloon enteroscopy, we can reach previously inaccessible areas changing the management of biliopancreatic diseases in patients with surgically altered anatomy. We report a case of single-balloon enteroscopy plus endoscopic retrograde cholangiopancreatography for the treatment of a pinpoint stricture in a hepaticojejunal anastomosis after liver transplantation.
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Affiliation(s)
- A Costa-Genzini
- Centro Avançado de Endoscopia Diagnóstica e Terapêutica, Hospital Santa Helena, Brazil.
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Elena RM, Riccardo U, Rossella C, Bizzotto A, Domenico G, Guido C. Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications. World J Gastrointest Endosc 2012; 4:453-461. [PMID: 23189216 PMCID: PMC3506955 DOI: 10.4253/wjge.v4.i10.453] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Enteroscopy, defined as direct visualization of the small bowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past several years. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies one of which is non-invasive, the video capsule, and a type of invasive technique, the device-assisted enteroscopy. In particular, the device-assisted enteroscopy consists then of three different types of instruments all able to allow, in skilled hands, to display partially or throughout its extension (if necessary) the small intestine. Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocarcinoma or gastrointestinal stromal tumors. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.
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Affiliation(s)
- Riccioni Maria Elena
- Riccioni Maria Elena, Unit of Digestive Endoscopy, Catholic University of Rome, Largo A Gemelli, 00168 Rome, Italy
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Prospective study of therapeutic spiral enteroscopy in patients with surgically altered anatomy. Surg Endosc 2012; 27:671-8. [DOI: 10.1007/s00464-012-2485-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 06/19/2012] [Indexed: 12/19/2022]
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Wagh MS, Draganov PV. Prospective evaluation of spiral overtube-assisted ERCP in patients with surgically altered anatomy. Gastrointest Endosc 2012; 76:439-43. [PMID: 22817798 DOI: 10.1016/j.gie.2012.04.444] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 04/06/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Mihir S Wagh
- Division of Gastroenterology, University of Florida, Gainesville, Florida 32610, USA
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'Short' double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 25:615-9. [PMID: 22059169 DOI: 10.1155/2011/354546] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:332-8. [PMID: 21140174 DOI: 10.1007/s00534-010-0361-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Roux-en-Y gastric bypass is increasingly performed in the United States. In addition, liver transplantation and other complex hepatobiliary surgeries are increasingly performed with creation of a Roux-en-Y hepaticojejunostomy. Consequently, endoscopists more frequently need to carry out endoscopic procedures in patients with Roux-en-Y anatomy. MATERIALS AND METHODS The present article discusses the techniques and instruments available to therapeutic endoscopists who are faced with the challenge of performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with long- or short-limb Roux-en-Y anatomy. CONCLUSION Endoscopists can successfully perform ERCP in patients with Roux-en-Y anatomy by making use of appropriate techniques and instruments.
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Kogure H, Watabe H, Yamada A, Isayama H, Yamaji Y, Itoi T, Koike K. Spiral enteroscopy for therapeutic ERCP in patients with surgically altered anatomy: actual technique and review of the literature. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:375-9. [PMID: 21116655 DOI: 10.1007/s00534-010-0357-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures are difficult to perform in patients with surgically altered anatomy. Recently, balloon enteroscopy (BE) has made it easier to perform ERCP in these patients. However, BE-assisted ERCP is often technically demanding and time consuming. METHODS Spiral enteroscopy (SE), which has recently been developed, is a novel method of using a rotating overtube to pleat small bowel onto the enteroscope, thus advancing it through the lumen. We review the mechanism and efficacy of SE, especially in ERCP of patients with surgically altered anatomy, and report on the first patient to undergo ERCP using SE in Japan. RESULTS Spiral enteroscopy-assisted ERCP seems to be feasible and safe in patients with surgically altered anatomy. Additionally, SE-assisted ERCP appears to be easier to perform than other methods previously described and allows stable positioning of the enteroscope in order to perform delicate therapeutic maneuvers. CONCLUSIONS SE for ERCP is expected to be at least as useful as balloon enteroscopy in patients with surgically altered anatomy.
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Affiliation(s)
- Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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Mönkemüller K, Jovanovic I. Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: A practical classification. World J Gastrointest Endosc 2011; 3:213-9. [PMID: 22110837 PMCID: PMC3221953 DOI: 10.4253/wjge.v3.i11.213] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 09/04/2011] [Accepted: 09/11/2011] [Indexed: 02/05/2023] Open
Abstract
AIM: To study the endoscopic and radiological characteristics of patients with hepaticojejunostomy (HJ) and propose a practical HJ stricture classification.
METHODS: In a retrospective observational study, a balloon-assisted enteroscopy (BAE)-endoscopic retrograde cholangiography was performed 44 times in 32 patients with surgically-altered gastrointestinal (GI) anatomy. BAE-endoscopic retrograde cholangio pancreatography (ERCP) was performed 23 times in 18 patients with HJ. The HJ was carefully studied with the endoscope and using cholangiography.
RESULTS: The authors observed that the hepaticojejunostomies have characteristics that may allow these to be classified based on endoscopic and cholangiographic appearances: the HJ orifice aspect may appear as small (type A) or large (type B) and the stricture may be short (type 1), long (type 2) and type 3, intrahepatic biliary strictures not associated with anastomotic stenosis. In total, 7 patients had type A1, 4 patients A2, one patient had B1, one patient had B (large orifice without stenosis) and one patient had type B3.
CONCLUSION: This practical classification allows for an accurate initial assessment of the HJ, thus potentially allowing for adequate therapeutic planning, as the shape, length and complexity of the HJ and biliary tree choice may mandate the type of diagnostic and therapeutic accessories to be used. Of additional importance, a standardized classification may allow for better comparison of studies of patients undergoing BAE-ERCP in the setting of altered upper GI anatomy.
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Affiliation(s)
- Klaus Mönkemüller
- Klaus Mönkemüller, Department of Internal Medicine, Gastroenterology and Infectious Diseases, Marienhospital Bottrop, Bottrop 46236, Germany
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Raithel M, Dormann H, Naegel A, Boxberger F, Hahn EG, Neurath MF, Maiss J. Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients. World J Gastroenterol 2011; 17:2302-14. [PMID: 21633596 PMCID: PMC3098398 DOI: 10.3748/wjg.v17.i18.2302] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Revised: 09/26/2010] [Accepted: 10/03/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions.
METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded.
RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%.
CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.
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Chennat J, Azzam R, Testa G. Endoscopic treatment of pediatric living donor liver transplant biliary-enteric stricture with small-caliber guidewire and angioplasty balloon. Pediatr Transplant 2011; 15:344-6. [PMID: 20825575 DOI: 10.1111/j.1399-3046.2010.01381.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
The Roux-en-Y gastric bypass (RYGB) accounts for more than 60% of bariatric procedures performed in the United States today. The RYGB anatomy poses particular challenges to interventional endoscopists who intend to access the papilla. Deep enteroscopy-assisted endoscopic retrograde cholangiopancreatography seems to be the least invasive technique for this purpose, and is often the best initial choice. However, considerable experience is needed to optimize the success rate of reaching the biliopancreatic limb, with subsequent successful cannulation, and which approach is taken should be determined on a case-by-case basis.
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Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc 2011; 25:2592-6. [PMID: 21416184 DOI: 10.1007/s00464-011-1593-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 08/17/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. The authors describe their technique, indications, and outcomes for this group of patients. METHODS Data were collected by a retrospective chart review of the experience two surgeons had with laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) from July 2004 to October 2008 at a single institution. This review identified 22 cases. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in 18 patients and recurrent pancreatitis in four patients. Adhesions were lysed, and a purse-string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery, and a 12 mm trocar was inserted. It was secured with a purse-string suture. A side-viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. The intended interventions were sphincter of Oddi manometry, sphincterotomy, placement of a pancreatic duct stent, and injection of botulinum toxin if indicated. RESULTS Laparoscopic access to the remnant stomach was sufficient for ERCP in 21 cases. One patient required conversion to an open procedure. A total of 12 patients had undergone prior open upper abdominal surgery. One retroperitoneal perforation was noted, with precut sphincterotomy and cannulation of the minor duodenal papilla and no clinical repercussions. Manometry was performed for 18 patients. The pancreatic duct cannulation rate for manometry was 89%, and the rate of bile duct cannulation for manometry was 94%. The manometry studies for 12 patients yielded abnormal results. Eight patients had transient improvement, and three patients had long-term improvement or resolution of symptoms after the index procedure. With additional treatment, two of the transient responders had long-term resolution of symptoms. CONCLUSIONS The findings demonstrate that gastric bypass patients with biliary pain can be successfully evaluated endoscopically by laparoscopic transgastric ERCP for sphincter of Oddi dysfunction. The rate for technical success and complications does not appear to be significantly greater than for standard ERCP. A few helpful techniques were noted during this experience. Comparison of efficacy with that of a prior study was limited.
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Affiliation(s)
- Peter M Bertin
- General Surgery, Department of Surgery, Westmoreland Hospital, Greensburg, PA, USA.
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Itoi T, Ishii K, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Tsuji S, Ikeuchi N, Umeda J, Tanaka R, Moriyasu F. Large balloon dilatation following endoscopic sphincterotomy using a balloon enteroscope for the bile duct stone extractions in patients with Roux-en-Y anastomosis. Dig Liver Dis 2011; 43:237-41. [PMID: 20947457 DOI: 10.1016/j.dld.2010.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 08/25/2010] [Accepted: 09/01/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extraction of bile duct stones in patients who have undergone Roux-en-Y anastomosis can be challenging. Recently, large balloon dilation following endoscopic sphincterotomy has been shown to be useful for the removal of bile duct stones. AIM We retrospectively evaluated the feasibility and safety of endoscopic sphincterotomy large balloon dilation for the removal of bile duct stones in patients with Roux-en-Y anastomosis. METHODS Large balloon papillary dilation following EST for the removal of bile duct stones was performed on the intact papilla in 15 patients with Roux-en-Y anastomosis at our institution. When we could not use the long-type accessories, a conventional forward-viewing upper endoscope passed through the over tube of the single-balloon or double-balloon enteroscope for the use of short-type accessories. Following endoscopic sphincterotomy, a large balloon catheter was positioned across the main duodenal papilla. The size of large balloon used ranged from 15mm to 20mm. RESULTS Complete clearance of bile duct stones was achieved in all cases in the initial session without any adverse events. A mechanical lithotriptor for crushing stones was used in one patient (6.7%). CONCLUSION Large balloon papillary dilation following EST appears to be an effective and safe treatment for difficult-to-remove bile duct stones in patients with Roux-en-Y anastomosis .
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, Japan
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Raithel M, Naegel A, Dormann H, deRossi T, Diebel H, Raithel S, Krauss F, Hahn EG, Maiss J. Modern enteroscopic interventions and characterization of nonmalignant postsurgical biliary anastomosis by double-balloon endoscopy. Surg Endosc 2011; 25:2526-35. [PMID: 21359896 DOI: 10.1007/s00464-011-1581-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 12/28/2010] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endoscopic access to strictured biliodigestive anastomoses often is difficult and may require percutaneous transhepatic biliary drainage or reoperation. METHODS Push- or push-and-pull enteroscopy was used to diagnose disease and treat 24 postsurgical patients with suspected strictured biliodigestive anastomosis. Endoscopic retrograde cholangiography and biliary interventional procedures were used. Endoscopic accessibility, diagnosis of disease, therapeutic success, and complication rates were investigated at a single tertiary university gastroenterology center. RESULTS Push enteroscopy reached biliary enteroanastomoses in 5 of the 24 patients (20.8%), whereas push-and-pull enteroscopy found choledocho- or hepaticojejunostomies in 17 of the remaining 19 postsurgical patients (89.4%). In all, successful enteroscopic intervention was achieved for 21 of the 24 patients (87.5%), whereas only 3 patients had to undergo percutaneous cholangiodrainage (12.5%). Cicatricially changed biliodigestive anastomoses were found in 14 of 21 patients (66.6%) including a mucosal type stricture in 7 patients (50%), an intramural type stricture in 5 patients (35.7%), and a ductal type stricture in 2 patients (14.2%). The remaining seven patients (33.3%) were normal. Enteroscopic interventions at strictured biliodigestive anastomosis included ostium incision for 8 (57.1%) and endoprosthesis insertion for 13 (92.8%) of the 14 patients, with prompt resolution of cholestasis and cholangitis. The major complications for the 24 patients involving 68 double-balloon enteroscopy (DBE) examinations comprised 2 perforations (8.3% per patient), 1 mild peritonitis (4.1%), and 1 cholangitis (4.1%), whereas minor complications were experienced by up to 20.8% of the patients. CONCLUSIONS Modern interventional enteroscopy yields a high rate of successful interventions for strictured biliodigestive anastomosis, requires ostium incision for mucosal and intramural types of strictures, and helps to reduce percutaneous approaches.
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Affiliation(s)
- M Raithel
- Department of Medicine I, Gastroenterology, Endoscopy, University of Erlangen, Erlangen, Germany.
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Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis. Surg Endosc 2010; 25:713-21. [PMID: 20976503 PMCID: PMC3044838 DOI: 10.1007/s00464-010-1226-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 11/12/2009] [Indexed: 02/06/2023]
Abstract
Background There have been a few previous reports on attempted double-balloon endoscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis and an intact papilla. This study was designed to evaluate the usefulness of DBE-assisted ERCP in patients with Roux-en-Y anastomosis and an intact papilla of Vater. Methods Thirteen DBE procedures were performed in nine patients who had undergone Roux-en-Y reconstruction combined with eight total gastrectomies and one partial gastrectomy. Both short-type and long-type DBE were used. Long-type DBE was replaced with a conventional forward-viewing upper endoscope after reaching the papilla. Technical success rate, measurement of procedure times, and adverse events were evaluated in the retrospective study. Results In all cases, the scopes could reach the papilla. The mean time required to reach the papilla was 48 (range, 13–90) min. There was a statistically significant difference with the short and long scope (29.0 ± 19.2 min vs. 64.8 ± 24.7 min, respectively; P = 0.044). The success rate of bile duct cannulation, resulting in achieving therapeutic ERCP on the first session was 66.7% (6/9). The mean procedural time in the successful cases was 128 (range, 47–183) min. Finally, therapeutic ERCP was achieved in all nine cases. There was one adverse event in which retroperitoneal perforation during lithotripsy, but that was successfully treated by conservative therapy alone. Conclusion DBE-assisted ERCP seems to be a promising option to perform therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis.
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Itoi T, Ishii K, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, Tsuji S, Ikeuchi N, Moriyasu F, Sakai Y. Ultrathin endoscope-assisted ERCP for inaccessible peridiverticular papilla by a single-balloon enteroscope in a patient with Roux-en-Y anastomosis. Dig Endosc 2010; 22:334-6. [PMID: 21175491 DOI: 10.1111/j.1443-1661.2010.01028.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We describe a case of successful endoscopic retrograde cholangiopancreatography (ERCP) using an ultrathin endoscope for inaccessible peridiverticular papilla by a single balloon enteroscopy (SBE) in a patient with Roux-en Y (R-Y). A 73-year-old man who had total gastrectomy with R-Y for gastric cancer was admitted for acute cholangitis. Although the SBE could be advanced to the end of the afferent loop, we could not identify a major papilla, although a duodenal diverticula could be observed. The enteroscope was replaced with an ultrathin endoscope. The ultrathin endoscope allowed the papilla to be detected distal to the side of the diverticula. After pre-cutting, the ultraslim endoscope was replaced with a conventional forward-viewing endoscope. Eventually, the stones were completely removed using a balloon catheter and basket without procedure-related complication.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Okabe Y, Kuwaki K, Kawano H, Kaji R, Sugiyama G, Ishida Y, Yasumoto M, Naito Y, Toyonaga A, Tsuruta O, Sata M. Direct cholangioscopy using a double-balloon enteroscope: choledochojejunostomy with intraductal biliary carcinoma. Dig Endosc 2010; 22:319-21. [PMID: 21175487 DOI: 10.1111/j.1443-1661.2010.01013.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A 75-year-old man who underwent choledochojejunostomy for gallstones 30 years ago was hospitalized for general malaise. Abdominal computed tomography revealed marked dilation of the intrahepatic bile duct in the right lobe and an image of a hypervascular tumor. Endoscopic retrograde cholangiography using double-balloon enteroscopy (DBE) showed a filling defect that was localized to the right hepatic bile duct. Furthermore, the scope was able to readily pass through the anastomosed site of the choledochojejunostomy and, therefore, we observed the interior of the bile duct using the same scope. We obtained an image showing a whitish, papillary-like tumor, and a biopsy of the tumor rendered the pathology of intraductal papillary mucinous carcinoma. Direct cholangioscopy using DBE is a useful diagnostic tool, particularly in patients with a past history of choledochojejunostomy.
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Affiliation(s)
- Yoshinobu Okabe
- Department of Medicine, Kurume University School of Medicine, Kurume, Japan.
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Lin CH, Tang JH, Cheng CL, Tsou YK, Cheng HT, Lee MH, Sung KF, Lee CS, Liu NJ. Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth II gastrectomy. World J Gastroenterol 2010; 16:4594-8. [PMID: 20857532 PMCID: PMC2945493 DOI: 10.3748/wjg.v16.i36.4594] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of double balloon endoscope (DBE) on the endoscopic retrograde cholangiopancreatography (ERCP) success rate in patients with a history of Billroth II (B II) gastrectomy.
METHODS: From April 2006 to March 2007, 32 patients with a B II gastrectomy underwent 34 ERCP attempts. In all cases, the ERCP procedures were started using a duodenoscope. If intubation of the afferent loop or reaching the papilla failed, we changed to DBE for the ERCP procedure (DBE-ERCP). We assessed the success rate of afferent loop intubation, reaching the major papilla, selective cannulation, possibility of therapeutic approaches, procedure-related complications, and the overall success rate.
RESULTS: Among the 32 patients with a history of B II gastrectomy, the duodenoscope was successfully passed up to the papilla in 22 patients (69%), and cannulation was successfully performed in 20 patients (63%). Six patients (2 with failure in afferent loop intubation and 4 with failure in reaching the papilla) underwent DBE-ERCP. The DBE reached the papilla in all the 6 patients (100%) and selective cannulation was successful in 5 patients (83%). Four patients (67%) who had common bile duct stones were successfully treated. One patient underwent diagnostic ERCP only and the other one, in whom selective cannulation failed, was diagnosed with papilla cancer proven by biopsy. There were no complications related to the DBE. The overall ERCP success rate increased to 88% (28/32).
CONCLUSION: The overall ERCP success rate increases with DBE in patients with a previous B II gastrectomy.
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Moreels TG, Pelckmans PA. Comparison between double-balloon and single-balloon enteroscopy in therapeutic ERC after Roux-en-Y entero-enteric anastomosis. World J Gastrointest Endosc 2010; 2:314-7. [PMID: 21160763 PMCID: PMC2999030 DOI: 10.4253/wjge.v2.i9.314] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 08/12/2010] [Accepted: 08/19/2010] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Tom G Moreels
- Tom G Moreels, Paul A Pelckmans, Division of Gastroenterology and Hepatology, Antwerp University Hospital, Wilrijkstraat 10, Antwerp B-2650, Belgium
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Layec S, D'Halluin PN, Pagenault M, Sulpice L, Meunier B, Bretagne JF. Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: a new role for double-balloon enteroscopy. Gastrointest Endosc 2010; 72:449-51. [PMID: 20541191 DOI: 10.1016/j.gie.2010.03.1063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 03/08/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic interventions are usually very challenging in patients with anatomic changes caused by earlier GI surgery. The recent development of the double-balloon enteroscopy (DBE) system creates an opportunity to reach the biliary tract and the pancreatic duct in postsurgical conditions. OBJECTIVE To report a further application of DBE in surgical patients; namely, extraction of pancreatic stents placed in pancreaticojejunal anastomosis during pancreaticoduodenectomy. DESIGN Two case reports. SETTING A single-center experience in a tertiary-care unit. PATIENTS AND INTERVENTIONS Two patients who underwent Whipple resection with Roux-en-Y reconstruction presented with migration of pancreatic stent tubes inserted in pancreaticojejunal anastomoses. Stents had migrated to the end of the afferent limb and were causing abdominal pain. Because extraction failed by using conventional endoscopy, we used the DBE system. MAIN OUTCOME MEASURES Successful extraction of the stents. RESULTS Stents were successfully removed in both patients with no complications. After 1 year of follow-up, the patients remained free of painful symptoms. LIMITATIONS Small volume case series. CONCLUSIONS Double-balloon enteroscopy is a reliable way to investigate and treat patients with postsurgical altered anatomy. Here, we report the successful removal of pancreatic stents migrating into the jejunal loop through pancreaticojejunal anastomosis.
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Affiliation(s)
- Sabrina Layec
- Service des maladies de l'appareil digestif, Centre hospitalo-universitaire, Rennes, France
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