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Balloon enteroscope for ERCP

Double- and single-balloon enteroscope equal for ERCP

ERCP at the level of the intact papilla in long limb Roux-en-Y is less successful, compared to short-limb or bilioenteric anastomosis

A study comparing the success and complication rate of double-balloon enteroscope (DBE) and single-balloon enteroscope (SBE) to perform endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y patients, has reported that both techniques are equally competent with high success rates and acceptable adverse events rates. However, the study authors from the Department of Gastroenterology & Hepatology, Antwerp University Hospital, Antwerp, Belgium, said that ERCP at the level of the intact papilla in long limb Roux-en-Y is less successful, compared to short-limb or bilioenteric anastomosis.

The paper, Comparison of double-balloon and single-balloon enteroscope for therapeutic endoscopic retrograde cholangiography after Roux-en-Y small bowel surgery’, published in BMC Gastroenterology, states that Roux-en-Y enteroenteric anastomosis can lead to adverse events like cholangitis and common bile duct stones however, this reconstruction excludes the afferent limb and the biliary tree from conventional endoscopic access. As a result, biliary adverse events often need percutaneous or even surgical intervention since ERCP using a conventional side-viewing duodenoscope is often not possible.

The authors note that in a ERCP procedure, Roux-en-Y reconstructions are divided in short-limb (<50 cm) and long-limb (≥100 cm) Roux-en-Y on the one hand, and bilioenteric/pancreatoenteric anastomosis versus intact Vater’s papilla on the other hand. Short-limb Roux-en-Y is used for bilioenteric/pancreatoenteric anastomosis and for (partial) gastrectomy with intact papilla, whereas long-limb Roux-en-Y in combination with intact papilla is used in several bariatric malabsorption surgical procedures.

The paper states that device-assisted enteroscopy, encompassing double-balloon (DBE), single-balloon (SBE) and spiral enteroscopy (SE) allows deep and even complete intubation of the small bowel. During DBE and SBE, a push-pull technique with a balloon-fitted overtube with (DBE) or without (SBE) a second balloon at the tip of the enteroscope is used to traverse the small bowel, whereas during SE a clockwise rotating overtube is employed. Fujinon DBE is commercially available since 2003 and Olympus SBE since 2007.

However, the authors state that there are few studies comparing different enteroscopy methods to perform ERCP after Roux-en-Y, therefore this study was established to compare the feasibility of DBE and SBE to perform ERCP in patients with Roux-en-Y altered small bowel anatomy.

Study

Seventy three Roux-en-Y patients with suspected biliary tract pathology underwent balloon-assisted enteroscopy in a tertiary-care centre. Retrospective analysis of 95 consecutive therapeutic ERCP procedures was performed to define and compare success and complication rate of DBE and SBE.

Male-female ratio was 28/45 with a mean age of 58±2 years. Thirty (32%) procedures were performed with DBE and 65 (68%) with SBE. Overall, ERCP success rate was 73% for DBE and 75% for SBE (p=0.831). Failure was due to inability to reach or cannulate the intact papilla or bilioenteric anastomosis. Success rate was significantly higher when performed at the bilioenteric anastomosis (80% success in 56 procedures) or at the intact papilla in short-limb Roux-en-Y (80% in 15 procedures) as compared to the intact papilla in long-limb (58 % in 24 procedures; p=0.040). Adverse event rates were 10% (DBE) and 8% (SBE) (p=0.707) and mostly dealt with conservatively.

Figure 1: Fluoroscopic image of the position of the enteroscope to obtain a cholangiogram in a 42-year old female patient with a history of gastric bypass bariatric surgery with Roux-en-Y reconstruction (LP)

“In our series, only the length of the Roux-en-Y limbs seemed to be a determining factor of ERCP success and not the presence of intact papilla or bilioenteric anastomosis. Although it was suggested before that an intact papilla is more difficult to cannulate as compared to a bilioenteric anastomosis, this was not the case in our large cohort,” they note. “Longer Roux-en-Y limbs decreased therapeutic success rates by limiting the access to the papilla. However, others have shown that even with the recently developed shorter versions (152 cm) of both DBE and SBE, ERCP was feasible in patients with altered intestinal anatomy, even in patients with long-limb Roux-en-Y. It seems however acceptable that longer Roux-en-Y limbs may render reaching the intact papilla more difficult, with a negative impact on therapeutic success rate.”

“The most important determining factor of therapeutic success seems the length of the Roux-en-Y limb,” the authors conclude. “Further development of the equipment (both endoscopes and catheters) is mandatory to improve the success of Roux-en-Y ERCP and to make it the first method of choice to deal with biliary pathology in patients with Roux-en-Y altered small bowel anatomy.”

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