DOUBLE BALLOON ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN ROUX‐EN‐Y ANASTOMOSIS PATIENTS

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of patients with pancreaticobiliary disorders, but endoscopic therapy is very difficult to carry out in patients with a Roux‐en‐Y anastomosis. We herein present the results of ERCP for patients with a Roux‐en‐Y anastomosis using a double‐balloon endoscope. Six patients (six men with a mean age of 69 years) who had undergone prior gastric resection with Roux‐en‐Y reconstruction were enrolled in the present study and underwent ERCP and associated procedures. ERCP was carried out with a double balloon endoscope, which has one balloon attached to the tip of the endoscope and another attached to the distal end of the soft overtube. In all patients, entering the Y loop was successfully accomplished, and the papilla of Vater was also reached in all cases (100%). Cannulation was successful in four patients (66.7%). The final diagnosis was choledocholithiasis in two patients, biliary fistula in one patient and pancreatic cancer in one patient. A needle‐knife precut papillotomy was carried out after placement of a bile duct stent in two patients, and injection of N‐butyl‐2‐cyanoacrylate into a biliary fistula was carried out in one patient. None of the patients suffered from any complications. A double balloon endoscope is therefore considered to be useful for carrying out ERCP and associated procedures in patients with a Roux‐en‐Y anastomosis.     

PANCREATIC PSEUDOCYSTS IN POST‐GASTRECTOMY PATIENTS TREATED VIA THE DUODENAL MINOR PAPILLA WITH AN OBLIQUE‐VIEWING ENDOSCOPE

Endoscopic retrograde cholangiopancreatography (ERCP) in patients after Billroth II or Roux‐en‐Y reconstruction is challenging because of difficulties in insertion of the endoscope into the afferent loop, which is a great distance away from the papilla of Vater, and cannulation into the desired duct from a reverse position. To facilitate ERCP, various endoscopes have been selected according to operator preference. Previously, we reported that an oblique‐viewing endoscope (XK‐200; Olympus, Tokyo, Japan) can contribute to successful performance of ERCP and associated procedures in Billroth II gastrectomy patients. We report here our experience with two post‐gastrectomy patients with chronic pancreatitis who were treated with an oblique‐viewing endoscope from the minor papilla.     

EXPERIENCES OF BILIARY INTERVENTIONS USING SHORT DOUBLE‐BALLOON ENTEROSCOPY IN PATIENTS WITH ROUX‐EN‐Y ANASTOMOSIS OR HEPATICOJEJUNOSTOMY

Background: The efficacy of double‐balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux‐en‐Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux‐en‐Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.     

OBLIQUE‐VIEWING ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATED PROCEDURES IN POST‐BILLROTH II GASTRECTOMY PATIENTS

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures have been reported to be difficult to perform in patients with Billroth II gastrectomy. We evaluated the feasibility of using an oblique‐viewing endoscope equipped with a cannula deflector for these procedures in such patients. Patients and Methods: Twenty‐four patients with Billroth II gastrectomy were enrolled in the present study and underwent ERCP, endoscopic sphincterotomy, endoscopic nasobiliary drainage, expandable metal stent placement or tube stent placement. All procedures were performed with an oblique‐viewing endoscope equipped with a cannula deflector. Results: In all patients, afferent loops were entered. Reaching the papilla of Vater was achieved in 22 (91.7%) patients, in whom all planned procedures were accomplished. One patient experienced acute pancreatitis, hemorrhage from the papilla of Vater after sphincterotomy, and intestinal perforation. Conclusions: We believe an oblique‐viewing endoscope equipped with a cannula deflector to be useful in performing ERCP and associated procedures in many patients with Billroth II gastrectomy. However, one should be aware of major complications, such as perforation, that may occur.     

ULTRATHIN ENDOSCOPE‐ASSISTED ERCP FOR INACCESSIBLE PERIDIVERTICULAR PAPILLA BY A SINGLE‐BALLOON ENTEROSCOPE IN A PATIENT WITH ROUX‐EN‐Y ANASTOMOSIS

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.     

Tips for double balloon enteroscopy in patients with Roux‐en‐Y reconstruction and modified Child surgery

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.     

EFFICACY AND SAFETY OF PROPHYLACTIC PANCREATIC DUCT STENT (PIT‐STENT) PLACEMENT IN PATIENTS AT HIGH RISK OF POST‐ERCP PANCREATITIS

Background: The usefulness of prophylactic pancreatic stent placement for preventing post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis has been reported. We developed a new pancreatic duct stent, which was a 5 Fr, 4 cm‐long stent with a single duodenal pigtail (Pit‐stent). Patients and Methods: Pancreatic duct stenting using a Pit‐stent was attempted in 76 patients (40 men, 36 women; mean age, 65 years; age range, 42–91 years) at high risk of post‐ERCP pancreatitis. The frequency of post‐ERCP pancreatitis and spontaneous passage of the stent were investigated. Results: Pancreatic duct stent placement was successfully performed in 93% of the patients. One patient developed mild pancreatitis after ERCP (1.4%). Spontaneous passage of the stent was observed in 92%. There were no other complications or procedure‐related deaths in this group. Conclusions: Pancreatic duct stent insertion may reduce the incidence of post‐ERCP pancreatitis in patients at high risk of post‐ERCP pancreatitis. Spontaneous migration of a pancreatic stent that contributes to a lessening of the need for additional ERCP can be expected with the use of a Pit‐stent.     

Tips and tricks of double‐balloon endoscopic retrograde cholangiopancreatography (with video)

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically difficult in patients with altered gastrointestinal tract, double‐balloon endoscopy (DBE) allows endoscopic access to pancreato‐biliary system in such patients. Balloon dilation of biliary stricture and extraction of bile duct stones, placement of biliary stent in patients with Roux‐en‐Y or Billroth‐II reconstruction, using DBE have been reported. However, two major technical parts are required for double‐balloon ERCP (DB‐ERCP). One is insertion of DBE and the other is an ERCP‐related procedure. The important point of DBE insertion is a sure approach to the afferent limb with Roux‐en‐Y reconstruction or Braun anastomosis. Short type DBE with working length 152 cm is beneficial for DB‐ERCP because it is short enough for most biliary accessory devices. In this paper, we introduce our tips and tricks for successful DB‐ERCP.     

ENDOSCOPIC OCCLUSION OF CYSTIC DUCT USING N‐BUTYL CYANOACRYLATE FOR POSTOPERATIVE BILE LEAKAGE

Bile leak after cholecystectomy is well described, with the cystic duct remnant the site of the leak in the majority of cases. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement has a high success rate in such cases. When ERCP fails, options include surgery, and percutaneous and endoscopic transcatheter occlusion of the site of bile leak. Here, we describe a case of endoscopic transcatheter occlusion of a persistent cystic duct bile leak after cholecystectomy using N‐butyl cyanoacrylate glue. A 51‐year‐old man had persistent pain and bilious drainage following a laparoscopic cholecystectomy. The bile leak persisted after endoscopic placement of a biliary stent for a confirmed cystic duct leak. A repeat ERCP was carried out and the cystic duct was occluded with a combination of angiographic coils and N‐butyl cyanoacrylate glue. The patient's pain and bilious drainage resolved. A follow‐up cholangiogram confirmed complete resolution of the cystic duct leak and a patent common bile duct.     

PROPHYLACTIC PANCREAS STENTING FOLLOWED BY NEEDLE‐KNIFE FISTULOTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION AND DIFFICULT CANNULATION: NEW METHOD TO PREVENT POST‐ERCP PANCREATITIS

Introduction: The aim of the present study was to reduce post‐endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle‐knife access fistulotomy and prophylactic pancreatic stenting in selected high‐risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. Methods: Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5×) pancreatic duct contrast filling, a prophylactic small calibre (3–5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle‐knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre‐cutting methods. Results: Prophylactic pancreatic stenting followed by needle‐knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post‐ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post‐ERCP pancreatitis cases. The frequency of post‐ERCP pancreatitis was significantly different: 0% versus 43%, as were the post‐procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. Conclusions: In selected, high‐risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle‐knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post‐ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.     

Reducing the risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis

Pancreatitis is the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in significant morbidity, occasional mortality, and increased health‐care expenditure. Accordingly, the prevention of post‐ERCP pancreatitis (PEP) remains a major clinical and research priority. Strategies to reduce the incidence of PEP include thoughtful patient selection, appropriate risk‐stratification, sound procedural technique, prophylactic pancreatic stent placement, and pharmacoprevention. Despite advances in all these areas, however, the incidence of PEP remains as high as 15% in high‐risk cases. Thus, additional research towards the goal of eliminating PEP is necessary. Herein is an evidence‐based review of strategies to prevent pancreatitis after ERCP, focusing on recent important developments in the field.