Use of the Conventional Side-viewing Duodenoscope for Successful Endoscopic Retrograde Cholangiopancreatography in Postgastrectomy Patients

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP. Methods: A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs). Results: Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3–89.4); I2: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4–99.4; I2: 0%) and 99.1% (95%CI: 98.6–99.7; I2: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3–78.0; I2: 86.9%) and 69.1% (95%CI: 65.3–72.9; I2: 91.8%) after EA-ERCP, 98% (95%CI: 96.5–99.6; I2: 0%) and 97.9% (95%CI: 96.3–99.4) after EDGE, and 98.6% (95%CI: 97.9–99.2; I2: 0%) and 98.5% (95%CI: 97.8–99.2; I2: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40–20.8); I2: 87.1%], and EDGE [13.1% (95%CI: 7.50–18.8); I2: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50–6.80); p ≤ 0.04; I2: 64.2%]. Conclusions: LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events.

Experience of endoscopic retrograde cholangiopancreatography with side-viewing duodenoscope in patients with previous gastric surgery

OBJECTIVES

Endoscopic Retrograde Cholangiopancreatography (ERCP) with conventional side-viewing duodenoscope can be challenging and unsuccessful at altered anatomy in the gastrointestinal tract. This study aimed to evaluate our experience with ERCP in patients with previous gastric surgery.

MATERIAL AND METHODS

Patients on whom ERCP was performed from January 2017 to August 2021 and who had previous gastric surgery were included into the study. Age, sex, comorbidity, Charlson's Comorbidity Index (CCI), ERCP indication, previous gastric surgery (indication, type of resection and reconstruction), history of cholecystectomy, and MRCP results were evaluated retrospectively. The results were compared as successful ERCP (SERCP) or unsuccessful ERCP (USERCP). Also, odds ratio ERCP failure was also evaluated.

RESULTS

Forty-three patients were included into study. Mean age was 68.8 ± 13.6 years. The most common sex was female (51.2%). The most common ERCP indication was choledocholithiasis with 44.2%, gastric surgery indication was peptic ulcer with 72.1%, gastric resection was subtotal with 67.4%, and reconstruction was gastrojejunostomy with 58.1%. The success rate of ERCP was 44.2%. Mean CCI was 4.16 ± 2.28. Only malignancy history was significantly higher in the USERCP group (p= 0.026). Male sex, non-choledocholithiasis indication, history of malignancy, CCI> 4, total gastrectomy, Roux-NY (RNY) reconstruction, history of cholecystectomy, and intercalarily to the bile duct dilatation in MRCP were likelihood for USERCP.

CONCLUSION

While history of malignancy and cholecystectomy were the only significant factor for unsuccessful ERCP, male sex, total gastrectomy, RNY anastomosis result in a higher likelihood of ERCP failure in patients with previous gastric surgery. Alternative devices to side-viewing duodenoscope will increase success in selected patients.

Outcomes and Loop Pattern Analysis of a Road-Map Technique for ERCP with Side-Viewing Duodenoscope in Patients with Billroth II Gastrectomy (with Video)

Endoscopic retrograde cholangiopancreatography (ERCP) in patients who have undergone a Billroth II gastrectomy is a major challenge. This study aimed to evaluate the outcomes of the road-map technique for duodenal intubation using a side-viewing duodenoscope for ERCP in Billroth II gastrectomy patients with naïve papilla, and to analyze the formation and release patterns of common bowel loops that occur when the duodenoscope navigates the afferent limb. The duodenoscopy approach success rate was 85.8% (97/113). In successful duodenoscopy approach patients, there were five bowel looping patterns that occurred when the preceding catheter-connected duodenoscope was advanced into the duodenum: (1) reverse ɣ-loop (29.9%), (2) fixed reverse ɣ-loop (5.2%), (3) simple U-loop (22.7%), (4) N-loop (28.9%), and (5) reverse alpha loop (13.4%). The duodenoscopy cannulation and duodenoscopy therapeutic success rates were 81.4% (92/113) and 80.5% (91/113), respectively, while the overall cannulation and therapeutic success rates were 92.0% (104/113) and 87.6% (99/113), respectively. Bowel perforation occurred in three patients (2.7%). The road-map technique may benefit duodenoscope-based ERCP in Billroth II gastrectomy patients by minimizing the tangential axis alignment between the duodenoscopic tip and driving of the afferent limb, and by predicting and counteracting bowel loops that occur when the duodenoscope navigates the afferent limb.

Endoscopic and percutaneous biliary interventions in patients with altered upper gastrointestinal anatomy-the Munich Multicenter Experience

BACKGROUND

In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era.

PATIENTS AND METHODS

Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed.

RESULTS

At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease.

CONCLUSION

In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.

Challenges of endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrointestinal anatomy: A review article

Endoscopic retrograde cholangiopancreatography (ERCP) is a combination of endoscopy and fluoroscopy that is commonly used in the management of pancreatobiliary diseases. ERCP can be challenging if performed in surgically altered anatomy, such as a Billroth II reconstruction, compared with native anatomy and usually has a lower success rate. We identified five emerging challenges in such patients. These are the choice of endoscope, the identification of afferent loop, reaching the duodenal stump, cannulation in the reverse position, and endoscopic sphincterotomy. Performing ERCP in patients with a Billroth II reconstruction needs adequate knowledge, proper skill, and experience to achieve a good clinical outcome.

Experience of the Endoscopists Matters in Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients

Background/Aims

Altered anatomy is a challenge in endoscopic retrograde cholangiopancreatography (ERCP) for patients with Billroth II anastomosis. In this study, we investigated the overall success and role of endoscopist experience.

Methods

Data of patients who underwent ERCP between 2014 and 2018 after a previous Billroth II operation were retrieved retrospectively from 2 tertiary ERCP centers. The procedures were performed by 2 endoscopists with different levels of experience. Clinical success was defined as extraction of the stone, placement of a stent through a malignant stricture, and clinical and laboratory improvements in patients.

Result

Seventy-five patients were included. The technical success rate was 83% for the experienced endoscopist and 75% for the inexperienced endoscopist (p=0.46). The mean (±standard deviation) procedure time was 23.8±5.7 min for the experienced endoscopist and 40.68±6.07 min for the inexperienced endoscopist (p<0.001). In total, 3 perforations (4%) were found. The rate of afferent loop perforation was 6.25% (1/16) for the inexperienced endoscopist and 0% (0/59) for the experienced endoscopist (p=0.053).

Conclusions

ERCP in patients who had undergone Billroth II gastrectomy was time consuming for the inexperienced endoscopist who should beware of the unique adverse events related to ERCP in patients with altered anatomy.

Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Recent advances in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: A systematic review

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy. However, there has been a paucity of comparative studies regarding ERCP in Billroth II gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations. This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth II gastrectomy patients.

AIM

To systematically review the literature regarding ERCP in Billroth II gastrectomy patients.

METHODS

A systematic review was performed on the literature published between May 1975 and January 2019. The following electronic databases were searched: PubMed, EMBASE, and Cochrane Library. The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed.

RESULTS

A total of 43 studies involving 2669 patients were included. The study designs were 36 (83.7%) retrospective cohort studies, 4 (9.3%) retrospective comparative studies, 2 (4.7%) prospective comparative studies, and 1 (2.3%) prospective cohort study. Of a total of 2669 patients, there were 1432 cases (55.6%) of side-viewing endoscopy, 664 (25.8%) cases of forward-viewing endoscopy, 171 (6.6%) cases of balloon-assisted enteroscopy, 169 (6.6%) cases of anterior oblique-viewing endoscopy, 64 (2.5%) cases of dual-lumen endoscopy, 31 (1.2%) cases of colonoscopy, and 14 (0.5%) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91.3% (2437/2669), and the overall success rate of selective cannulation was 87.9% (2346/2437). A total of 195 cases (7.3%) of adverse events occurred. The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows: side-viewing endoscopy 98.2% and 95.3%; forward-viewing endoscopy 97.4% and 95.2%; balloon-assisted enteroscopy 95.4% and 97.5%; oblique-viewing endoscopy 94.1% and 97.5%; and dual-lumen endoscopy 82.8% and 100%, respectively. The rate of bowel perforation was slightly higher in side-viewing endoscopy (3.6%) and balloon-assisted enteroscopy (4.1%) compared with forward-viewing endoscopy (1.7%) and anterior oblique-viewing endoscopy (1.2%). Mortality only occurred in side-viewing endoscopy (n = 9, 0.6%).

CONCLUSION

The performance of ERCP in the Billroth II gastrectomy population has been improving with choice of various type of endoscope and sphincter management. More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth II gastrectomy patients.

Forward-viewing endoscope for ERCP in patients with Billroth II gastrectomy: a systematic review and meta-analysis

BACKGROUND

The forward-viewing endoscope has been increasingly used to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent Billroth II gastrectomy. This study intended to assess efficacy and safety of the forward-viewing endoscope for ERCP in Billroth II gastrectomy patients compared with conventional side-viewing endoscope using a systematic review and meta-analysis.

METHODS

A systematic review was conducted for studies that evaluated the outcomes of ERCP for patients with Billroth II gastrectomy. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for non-randomized studies. The publication bias was assessed.

RESULTS

In total, 25 studies (1 randomized, 18 retrospective, 1 prospective, and 5 case series studies) with 2446 patients (499 forward-viewing and 1947 side-viewing endoscopes) were analyzed. The pooled afferent loop intubation rate was higher with the forward-viewing endoscope (90.3%, 95% confidence interval (CI) 85.6-93.6 vs. 86.8%, 95% CI 82.8-89.9%). The pooled selective cannulation rate was higher with the side-viewing endoscope (92.3%, 95% CI 88.0-95.2 vs. 91.1%, 95% CI 87.2-93.9%). The pooled bowel perforation rate was higher with the side-viewing endoscope (3.6%, 95% CI 2.3-5.7 vs. 3.0%, 95% CI 1.7-5.3%). The pooled pancreatitis rate was higher with the forward-viewing endoscope (5.4%, 95% CI 3.6-8.0 vs. 2.5%, 95% CI 2.3-5.7%). The pooled bleeding rate was higher with the forward-viewing endoscope (3.0%, 95% CI 1.6-5.5 vs. 2.0%, 95% CI 1.4-3.0%). The heterogeneity among the studies was not significant. The publication bias was minimal.

CONCLUSION

This meta-analysis indicates that the forward-viewing endoscope is as safe and effective as conventional side-viewing endoscope for ERCP in patients with Billroth II gastrectomy.

Endoscopic management of bile duct stones in patients with surgically altered anatomy

Bile duct stones in patients with surgically altered anatomy still pose a challenge to endoscopists. For successful endoscopic management of bile duct stones, there are multiple hurdles: Intubation to the afferent limb, biliary cannulation, ampullary intervention and stone extraction. The major advancement in this area is the development of dedicated device-assisted endoscopes for endoscopic retrograde cholangiopancreatography (ERCP). In patients with Billroth II reconstruction, a high technical success rate is reported using a duodenoscope but can be complicated by a potentially high perforation rate. In patients with Roux-en-Y reconstruction, device-assisted ERCP shows high technical success and low adverse event rates. Meanwhile, endoscopic papillary large balloon dilation enables safe and effective stone extraction with less use of endoscopic mechanical lithotripsy in patients with a dilated distal bile duct, but intraductal lithotripsy is sometimes necessary for management of very large bile duct stones. In cases with difficult stones, alternative approaches such as laparoscopy-assisted ERCP and endoscopic ultrasound (EUS)-guided intervention are increasingly reported with preliminary but promising results. However, comparative studies are still lacking in this area and prospective randomized controlled trials are warranted in terms of safety, efficacy and cost-effectiveness.

Antegrade jejunogastric intussusception and common bile duct stones at 14 months after gastrectomy and cholecystectomy: A case report

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Jejunogastric intussusception occurred after distal gastrectomy followed by Roux-en Y reconstruction.

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Common bile duct stone occurred after prophylactic cholecystectomy and distal gastrectomy.

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Intussusception and common bile duct stone both could occur simultaneously after gastrectomy.

Introduction

Intussusception after gastrectomy is a minor complication after gastrectomy, while common bile duct stone (CBD) is also a rare complication post cholecystectomy. We report a case that simultaneously caused both intussusception and CBD stone following gastrectomy with prophylactic cholecystectomy.

Case presentation

A 74-year-old woman underwent distal gastrectomy with Roux-en-Y reconstruction and prophylactic cholecystectomy for gastric cancer. After 14 months, the patient reported nausea and vomiting. Abdominal computed tomography scanning showed antegrade intussusception of the Roux limb of the gastrojejunostomy and calculi in the common bile duct, with a diagnosis of jejunogastric intussusception and common bile duct stones. The patient was hospitalized and endoscopic examination was performed on day 3. Endoscopic treatment did not resolve the intussusception, which also obstructed the bile duct stones. Elective surgery was performed on day 10, in which the invaginated Roux limb of the gastrojejunostomy was resected after manual reinstatement to its original position. This was followed by open exploration of the common bile duct and T-tube drainage. The patient was discharged 25 days post- surgery.

Discussion

Jejunogastric intussusception and CBD stone may require operative management, although the operation could be elective after sufficient examination and preparation.

Conclusion

Jejunogastric intussusception and bile duct stones are rare after distal gastrectomy, physicians should be alerted to the possibility of these complications.