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Nehme F, Goyal H, Perisetti A, Tharian B, Sharma N, Tham TC, Chhabra R. The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy. Front Med (Lausanne) 2022; 8:792668. [PMID: 35004760 PMCID: PMC8733321 DOI: 10.3389/fmed.2021.792668] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/22/2021] [Indexed: 12/11/2022] Open
Abstract
The introduction of capsule endoscopy in 2001 opened the last "black box" of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy are available in clinical practice. Recently, a novel motorized enteroscope has been described with the potential to shorten procedure time and allow for total enteroscopy in one session. In this review, we will present an overview of the currently available techniques, indications, diagnostic yield, and complications of device-assisted enteroscopy.
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Affiliation(s)
- Fredy Nehme
- Department of Gastroenterology and Hepatology, School of Medicine, Saint Luke's Hospital, University of Missouri Kansas City (UMKC), Kansas City, MO, United States
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Abhilash Perisetti
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, IN, United States
| | - Benjamin Tharian
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Neil Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, IN, United States.,Department of Endoscopy, Indiana University School of Medicine, Fort Wayne, IN, United States
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, United Kingdom
| | - Rajiv Chhabra
- Department of Gastroenterology and Hepatology, School of Medicine, Saint Luke's Hospital, University of Missouri Kansas City (UMKC), Kansas City, MO, United States
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García M, Esquivel C, Palermo M. Common Bile Duct Stones After Roux-en-Y Gastric Bypass: Same Issue, Different Ways to Deal with. J Laparoendosc Adv Surg Tech A 2020; 30:900-906. [PMID: 32423282 DOI: 10.1089/lap.2020.0269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Obesity is a complex chronic disease, which represents a severe and growing health issue all over the world. Bariatric surgery is an option when medical treatments failed. The average of complications is low. Common bile duct stones in a patient who underwent weight loss surgery, especially Roux-en-Y gastric bypass, one anastomosis gastric bypass, or duodenal switch, is challenging due to the difficult access to the biliary duct. Methods: We describe the different techniques we used to perform the treatment of common bile duct stones after a gastric bypass was performed. Results: The highlights of the different treatments to solve this big issue that is common bile duct after gastric bypass are described, such as the endoscopic, the surgical, the percutaneous, and combined ones. Conclusion: There are several therapeutic options; many of them have already demonstrated excellent results. Even though there is not a gold standard technique, the total endoscopic approach performed by trained hands should be the first line of treatment. Percutaneous approach represents also a safe and effective option that can avoid reoperations in an important number of patients. However, the choice will depend on the severity of the case to face with, the availability of resources, and the experience of the team.
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Affiliation(s)
- Manuel García
- Division of Bariatric and Metabolic Surgery, Sanatorio Allende Hospital, Córdoba, Argentina
| | - Carlos Esquivel
- Division of Bariatric and Metabolic Surgery, Sanatorio Allende Hospital, Córdoba, Argentina
| | - Mariano Palermo
- Division of Bariatric and Metabolic Surgery, Centro CIEN-Diagnomed and DAICIM Foundation, Buenos Aires, Argentina
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Pancreatic Head Resection Following Roux-en-Y Gastric Bypass: Operative Considerations and Outcomes. J Gastrointest Surg 2020; 24:76-87. [PMID: 31485901 DOI: 10.1007/s11605-019-04366-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/12/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE This study aimed to identify optimal management decisions for surgeons preforming pancreatic head resection on patients with altered anatomy due to a previous Roux-en-Y gastric bypass (RYGB). METHODS A multi-national (4), multi-center (28) collaborative of 55 pancreatic surgeons who have performed pancreatoduodenectomy or total pancreatectomy following RYGB for obesity (2005-2018) was created. Demographics, operative details, and perioperative outcomes from this cohort were analyzed and compared in a propensity-score matched analysis with a multi-center cohort of 5533 pancreatoduodenectomies without prior RYGB. RESULTS Ninety-six patients with a previous RYGB undergoing pancreatic head resection were assembled. Pathologic indications between the RYGB and normal anatomy cohorts did not differ. Propensity score matching of RYGB vs. patients with unaltered anatomy demonstrated no differences in major postoperative outcomes. In total 20 distinct reconstructions were employed (of 37 potential options); the three most frequent reconstructions accounted for 52.1%, and none demonstrated superior outcomes. There were no differences in outcomes observed between original biliopancreatic limb use (66.7%) and those where a secondary Roux limb was created for biliopancreatic reconstruction. Remnant stomachs were removed in 54.7% of cases, with no outcome differences between resected and retained stomachs. Venting gastrostomy tubes were used in 36.2% of retained stomachs without obvious outcome benefits. Jejunostomy tubes were used infrequently (11.7%). CONCLUSIONS Pancreatic head resection after RYGB is an infrequently encountered, unique and challenging scenario for any given surgeon. These patients do not appear to suffer higher morbidity than those with unaltered anatomy. Various technical reconstructive options do not appear to confer distinct benefits.
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Morano WF, Shaikh MF, Gleeson EM, Galvez A, Khalili M, Lieb J, Renza-Stingone EP, Bowne WB. Reconstruction options following pancreaticoduodenectomy after Roux-en-Y gastric bypass: a systematic review. World J Surg Oncol 2018; 16:168. [PMID: 30103758 PMCID: PMC6090772 DOI: 10.1186/s12957-018-1467-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 08/03/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Obesity is a risk factor for pancreatic cancer which may be treated with Roux-en-Y gastric bypass and represents an increasing morbidity. Post-RYGB anatomy poses considerable challenges for reconstruction after pancreaticoduodenectomy (PD), a growing problem encountered by surgeons. We characterize specific strategies used for post-PD reconstruction in the RYGB patient. METHODS PubMed search was performed using MeSH terms "Gastric Bypass" and "Pancreaticoduodenectomy" between 2000 and 2018. Articles reporting cases of pancreaticoduodenectomy in post-RYGB patients were included and systematically reviewed for this study. RESULTS Three case reports and five case series (25 patients) addressed PD after RYGB; we report one additional case. The typical post-gastric bypass PD patient is a woman in the sixth decade of life, presenting most commonly with pain (69.2%) and/or jaundice (53.8%), median 5 years after RYGB. Five post-PD reconstructive options are reported. Among these, the gastric remnant was resected in 18 cases (69.2%), with reconstruction of biliopancreatic drainage most commonly achieved using the distal jejunal segment of the pre-existing biliopancreatic limb (73.1%). Similarly, in the eight cases where the gastric remnant was spared (30.8%), drainage was most commonly performed using the distal jejunal segment of the biliopancreatic limb (50%). Among the 17 cases reporting follow-up data, median was 27 months. CONCLUSION Reconstruction options after PD in the post-RYGB patient focus on resection or preservation gastric remnant, as well as creation of new biliopancreatic limb. Insufficient data exists to make recommendations regarding the optimal reconstruction option, yet surgeons must prepare for the possible clinical challenge. PD reconstruction post-RYGB requires evaluation through prospective studies.
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Affiliation(s)
- William F. Morano
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - Mohammad F. Shaikh
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - Elizabeth M. Gleeson
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - Alvaro Galvez
- Division of Minimally Invasive Surgery, Department of Surgery, Drexel University College of Medicine, 245 N. 15th St, Suite 7150, Philadelphia, PA 19102 USA
| | - Marian Khalili
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - John Lieb
- Division of Gastroenterology & Hepatology, Department of Medicine, Drexel University College of Medicine, 219 N Broad St, 5th Floor, Philadelphia, PA 19107 USA
| | - Elizabeth P. Renza-Stingone
- Division of Minimally Invasive Surgery, Department of Surgery, Drexel University College of Medicine, 245 N. 15th St, Suite 7150, Philadelphia, PA 19102 USA
| | - Wilbur B. Bowne
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
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Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN. Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc 2018; 87:1241-1247. [PMID: 29317267 DOI: 10.1016/j.gie.2017.12.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 12/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. METHODS This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. RESULTS Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. CONCLUSION With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.
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Affiliation(s)
- Mohammad F Ali
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | - Rani Modayil
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | - Krishna C Gurram
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
| | | | - David Friedel
- Department of Gastroenterology, Hepatology and Nutrition, NYU Winthrop Hospital, Mineola, New York
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Docimo S, Svestka M. Endoscopic Evaluation and Treatment of Postoperative Bariatric Surgery Complications. Surg Innov 2017; 24:616-624. [PMID: 29072533 DOI: 10.1177/1553350617736651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The number of patients undergoing bariatric surgery continues to increase. The American Society for Metabolic and Bariatric Surgery (ASMBS) estimates the number of bariatric surgical procedures performed increased from 158 000 in 2011 to 190 000 in 2015. Concurrently, the incidence of postoperative complications specific to bariatric patients will inevitably increase as well. Endoscopic evaluation of postoperative bariatric patients and endoscopic interventions are rapidly evolving. We present a review of the postoperative anatomy of bariatric patients, what complications to expect, and treatment options.
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7
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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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8
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Khashab MA, El Zein MH, Sharzehi K, Marson FP, Haluszka O, Small AJ, Nakai Y, Park DH, Kunda R, Teoh AY, Peñas I, Perez-Miranda M, Kumbhari V, Van der Merwe S, Artifon EL, Ross AS. EUS-guided biliary drainage or enteroscopy-assisted ERCP in patients with surgical anatomy and biliary obstruction: an international comparative study. Endosc Int Open 2016; 4:E1322-E1327. [PMID: 27995197 PMCID: PMC5161123 DOI: 10.1055/s-0042-110790] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/13/2016] [Indexed: 02/07/2023] Open
Abstract
Background and study aims: How enteroscopy-assisted ERCP (e-ERCP) and endoscopic ultrasound-guided biliary drainage (EUS-BD) compare in patients with surgically altered upper gastrointestinal anatomy is currently unknown. The aims of this study were to compare efficacy and safety of both techniques and study predictors of these outcomes. Patients and methods: This was an international, multicenter comparative cohort study at 10 tertiary centers. Outcomes data included technical success (biliary access with cholangiography and stent placement [when indicated]), clinical success (resolution of biliary obstruction) and adverse events (AEs) (graded according to the ASGE lexicon). Results: A total of 98 patients underwent EUS-BD (n = 49) or e-ERCP (n = 49). Technical success was achieved in 48 (98 %) patients in the EUS-BD group as compared to 32 (65.3 %) patients in the e-ERCP group (OR 12.48, P = 0.001). Clinical success was attained in 88 % of patients in EUS-BD group as compared to 59.1 % in the e-ERCP group (OR 2.83, P = 0.03). Procedural time was significantly shorter in the EUS-BD group (55 min vs 95 min, P < 0.0001). AEs occurred more commonly in the EUS-BD group (20 % vs. 4 %, P = 0.01). However, the majority (90 %) of AEs were mild/moderate. Length of stay was significantly longer in the EUS-BD group (6.6 d vs. 2.4 d, P < 0.0001). Conclusions: EUS-BD can be performed with a higher degree of clinical efficacy and shorter procedure time than e-ERCP in patients with surgically-altered upper gastrointestinal anatomy. Whether or not this approach should be first-line therapy in this patient population is highly dependent on the indication for the procedure, the patient's anatomy, and local practice and expertise.
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Affiliation(s)
- Mouen A. Khashab
- Division of Gastroenterology and Hepatology,
The Johns Hopkins Medical Institutions, Baltimore, MD, United
States,Corresponding author Mouen A. Khashab,
MD Associate Professor of
MedicineDirector of Therapeutic
EndoscopyJohns Hopkins
Hospital1800 Orleans St, Suite 7125
BBaltimore, MD
21205+1-443-287-1960
| | - Mohamad H. El Zein
- Division of Gastroenterology and Hepatology,
The Johns Hopkins Medical Institutions, Baltimore, MD, United
States
| | - Kaveh Sharzehi
- Division of Gastroenterology and Hepatology,
Temple University Hospital, Philadelphia, PA, United States
| | | | - Oleh Haluszka
- Division of Gastroenterology and Hepatology,
Temple University Hospital, Philadelphia, PA, United States
| | - Aaron J. Small
- Division of Hepatology and Gastroenterology,
Virginia Mason Medical Center, Seattle, WA, United States
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate
School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Do Hyun Park
- Department of Internal Medicine, University
of Ulsan College of Medicine, Asan Medical Center, Seoul, South
Korea
| | - Rastislav Kunda
- Department of Surgical Gastroenterology,
Aarhus University Hospital, Aarhus, Denmark
| | - Anthony Y. Teoh
- Department of Surgery, The Chinese University
of Hong Kong, Hong Kong, China
| | - Irene Peñas
- Hospital Universitario Rio Hortega,
Valladolid University, Valladolid, Spain
| | | | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology,
The Johns Hopkins Medical Institutions, Baltimore, MD, United
States
| | | | | | - Andrew S. Ross
- Division of Hepatology and Gastroenterology,
Virginia Mason Medical Center, Seattle, WA, United States
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10
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Abstract
ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates.
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11
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The role of deep enteroscopy in the management of small-bowel disorders. Gastrointest Endosc 2015; 82:600-7. [PMID: 26253015 DOI: 10.1016/j.gie.2015.06.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 06/23/2015] [Indexed: 12/11/2022]
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Hatzaras I, Sachs TE, Weiss M, Wolfgang CL, Pawlik TM. Pancreaticoduodenectomy after bariatric surgery: challenges and available techniques for reconstruction. J Gastrointest Surg 2014; 18:869-77. [PMID: 24281775 DOI: 10.1007/s11605-013-2418-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/13/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Obesity is an epidemic in the U.S.A., with approximately 7% of the population considered morbidly obese (BMI > 40 or >35 with significant comorbidities). DISCUSSION Weight loss surgery is recognized as a durable solution to both obesity and obesity-associated morbidities. With an increasing number of pancreatic lesions being discovered on cross-sectional imaging, the pancreatic surgeon is increasingly likely to encounter patients with prior bariatric surgery who are in need of pancreaticoduodenectomy. As such, surgeons need to be familiar with the various bariatric operations, as well as the manner in which to handle prior bariatric reconstructions at the time of pancreatic surgery. Literature on this topic, however, is scarce with only a handful of small case series. CONCLUSION We herein review the different operations performed for weight loss, as well as provide an overview of the available operative approaches for reconstruction after pancreaticoduodenectomy in postbariatric surgical patients.
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Affiliation(s)
- Ioannis Hatzaras
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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13
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ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013. [PMID: 23793801 DOI: 10.1007/s00464-013-3129-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy. METHODS Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician. RESULTS Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p < 0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022). CONCLUSIONS GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.
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14
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Choi EK, Chiorean MV, Coté GA, El Hajj II, El Hajj I, Ballard D, Fogel EL, Watkins JL, McHenry L, Sherman S, Lehman GA. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013; 27:2894-9. [PMID: 23793801 DOI: 10.1007/s00464-013-2850-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 01/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy. METHODS Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician. RESULTS Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p < 0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022). CONCLUSIONS GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.
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Affiliation(s)
- Eun Kwang Choi
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, 550 N. University Boulevard, UH 4100, Indianapolis, IN 46202, USA
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15
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Lee A, Shah JN. Endoscopic approach to the bile duct in the patient with surgically altered anatomy. Gastrointest Endosc Clin N Am 2013; 23:483-504. [PMID: 23540972 DOI: 10.1016/j.giec.2012.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy can be technically challenging, because of three main problems that must be overcome: (1) endoscopically traversing the altered luminal anatomy, (2) cannulating the biliary orifice from an altered position, and (3) performing biliary interventions with available ERCP instruments. This article addresses the most common and most challenging variations in anatomy encountered by a gastroenterologist performing ERCP. It also highlights the innovations and progress that have been made in coping with these anatomic variations, with special attention paid to altered anatomy from bariatric surgery.
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Affiliation(s)
- Alexander Lee
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA 94143, USA
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