Endoscopic retrograde cholangiography with a single-balloon enteroscope in patients with Roux-en-Y hepatico jejunal anastomosis

Czech version

Authors: B. Kianička ¹; I. Novotný ²; P. Vlček ³; J. Korbička ³; P. Piskač ³; J. Žák ³; M. Souček ¹; J. Špác ¹; I. Řiháček ¹
Authors‘ workplace: II. interní klinika Lékařské fakulty MU a FN u sv. Anny Brno, přednosta prof. MUDr. Miroslav Souček, CSc. ¹; Gastroenterologické oddělení Masarykova onkologického ústavu Brno, přednostka prim. MUDr. Milana Šachlová, Ph. D. ²; I. chirurgická klinika Lékařské fakulty MU a FN u sv. Anny Brno, přednosta prof. MUDr. Ivan Čapov, CSc. ³
Published in: Vnitř Lék 2012; 58(5): 347-353
Category: Original Contributions

Overview

Aims of the study:
The aim of this retrospective study was to evaluate our experience with using a single-balloon enetroscope for diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepatico jejunal anastomosis (HJA). Due to the considerably changed anatomic circumstances after the surgery, ERC is, in comparison to the standard endoscopic retrograde cholangiopancraeaticography (ERCP), significantly more difficult to perform.

Patient sample and methodology:
The sample was followed upFrom January 2009 to September 2011. The study retrospectively reviewed 14 patients with Roux-en-Y HJA with symptoms of biliary obstruction. A total of 21 ERCs were performed in these 14 Roux-en-Y HJA patients using the single-balloon videoenetroscope Olympus SIF Q 180.

Results:
Diagnostic ERC cannulation was successful in 11 of the 14 patients (79% success rate for the diagnostic ERC). One of the 11 patients had a normal finding on the ERC. The remaining 10 patients had a pathological finding on ERC that, in one patient (cystic dilatation of bile duct), was subsequently managed surgically. Endoscopic treatment was initiated in the remaining 9 patients (HJA stenosis in 4, choledocholithiasis in 2 and concurrent HJA stenosis and choledocholithiasis in 3) immediately after the diagnostic ERC; the surgery was successful in 8 of the 9 patients (89% success rate for the therapeutic ERC). The performed endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis 9 times (6 patients), choledocholithiasis extraction – 5 times (5 patients), biliary plastic stent placement – 5 times (3 patients), removal of biliary stents placed by us – 5 times (3 patients). We did not observe any complications in our sample of 14 patients.

Conclusions:
ERC using a single-balloon enteroscope in patients with Roux-Y HJA is significantly more difficult than the standard ERCP due to different post-surgical anatomy. In our sample of patients, we achieved 79% success rate for the diagnostic ERC and 89% success rate for the therapeutic ERC. Additional time should be allowed for the individual procedures. Furthermore, the presence of an anaesthesiologist during these operations (deep analgosedation) is essential. This is a technically very demanding technique that, however, is effective and safe and importantly extends the options available for the management of biliary pathologies in these patients.

Key words:
endoscopic retrograde cholangiography – single balloon enteroscopy – Roux-en-Y hepatico jejunal anastomosis – endoscopic treatment

Sources

1. Třeška V, Skalický T, Šafránek J et al. Poranění žlučových cest při cholecystektomii. Rozhl Chir 2005; 84: 13–18.

2. Král V, Havlík R, Neoral Č. Hepatikojejunoanastomóza: ,,zlatý standard“ při rekonstrukci žlučových cest po jejich poranění. HPB 2003; 11: 2.

3. Ehrmann J, Hůlek P et al. Hepatologie. Praha: Grada Publishing 2010.

4. Aabakken L, Bretthauer M, Line PD. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy 2007; 39: 1068–1071.

5. Mönkemüller K,Fry LC, Bellutti M et al. ERCP with the double balloon enteroscope in patients with Roux-en-Y anastomosis. Surg Endosc 2009; 23: 1961–1967.

6. Tsujikawa T, Saitoh Y, Andoh A et al. Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences. Endoscopy 2008; 40: 11–15.

7. Machková N, Bortlík M, Bouzková E et al. Jednobalonová enteroskopie u nemocných s Crohnovou chorobou – zkušenosti jednoho centra. Gastroent Hepatol 2011; 65: 215–219.

8. Koornstra JJ,Fry L, Mönkemüller K. ERCP with the balloon-assisted enteroscopy technique: a systematic review. Dig Dis 2008; 26: 324–329.

9. Vavrečka A. Diagnostická a liečebná endoskopia žlčových ciest a pankreatu. Bratislava: Osveta 1988.

10. Urban O, Chalupa J. Cysta choledochu. Vnitř Lék 1996; 42: 418–419.

11. Keil R. Akutní biliární pankreatitida – endoskopická terapie ano nebo ne? Vnitř Lék 2002; 48: 847–850.

12. Saleem A, Baron TH, Gostout CJ et al. Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy. Endoscopy 2010; 42: 656–660.

13. Wang AY, Sauer BG, Behm BW et al. Single-balloon enteroscopy effectively enables diagnostic and therapeutic retrograde cholangiography in patients with sugrically altered anatomy. Gastrointest Endosc 2010; 71: 641–649.

14. Haber GB. Double balloon endoscopy for pancreatic and biliary access in altered anatomy. Gastrointest Endosc 2007; 66 (Suppl 1): S47–S50.

15. Mönkemüller K,Fry LC, Bellutti M et al. ERCP using single-balloon instead of double-balloon enteroscopy in patients with Roux-en-Y anastomosis. Endoscopy 2008; 40 (Suppl 2): E19–E20.

16. Kuga R, Furuya CK Jr, Hondo FY et al. ERCP using double-balloon enteroscopy in patients with Roux-en-Y anatomy. Dig Dis 2008; 26: 330–335.

17. Parlak E, Cicek B, Disibeyaz S et al. Endoscopic retrograde cholangiography by double-balloon enteroscopy in patients with Roux-en-Y hepaticojejunostomy. Surg Endosc 2010; 24: 466–470.

18. Mönkemüller K, Weigt J, Treiber G et al. Diagnostic and therapeutic impact of double-balloon enteroscopy. Endoscopy 2006; 38: 67–72.

19. Itoi T, Ishii K, Sofuni A et al. Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video). Am J Gastroenterol 2010; 105: 93–99.

20. Dellon ES, Kohn GP, Morgan DR et al. Endoscopic retrograde cholangiopancreatography with single-balloon enteroscopy is feasible in patients with a prior Roux-en-Y anastomosis. Dig Dis Sci 2009; 54: 1798–1803.

21. Neumann H,Fry LC, Meyer F et al. Endoscopic retrograde cholangiopancreatography using the single balloon enteroscope technique in patients with Roux-en-Y anastomosis. Digestion 2009; 80: 52–57.