Clin Endosc.  2015 Sep;48(5):452-457. 10.5946/ce.2015.48.5.452.

Single Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients Who Underwent a Gastrectomy with Roux-en-Y Anastomosis: Six Cases from a Single Center

• Soh JS
• Yang DH
• Lee SS
• Lee S
• Bae J
• Byeon JS
• Myung SJ
• Yang SK

• KMID: 2148561
• DOI: http://doi.org/10.5946/ce.2015.48.5.452

Abstract

Patients with altered anatomy such as a Roux-en-Y anastomosis often present with various pancreaticobiliary problems requiring therapeutic intervention. However, a conventional endoscopic approach to the papilla is very difficult owing to the long afferent limb and acute angle of a Roux-en-Y anastomosis. Balloon-assisted enteroscopy can be used for endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered anatomy. We experienced six cases of Roux-en-Y anastomosis with biliary problems, and attempted ERCP using single balloon enteroscopy (SBE). SBE insertion followed by replacement with a conventional endoscope was attempted in five of six patients. The papilla was successfully approached using SBE in all cases. However, therapeutic intervention was completed in only three cases because of poor maneuverability caused by postoperative adhesion. We conclude that in patients with Roux-en-Y anastomosis, the ampulla can be readily accessed with SBE, but longer dedicated accessories are necessary to improve this therapeutic intervention.

Keyword

Single balloon enteroscopy; Cholangiopancreatography, endoscopic retrograde; Anastomosis, Roux-en-Y

MeSH Terms

Anastomosis, Roux-en-Y*
Cholangiopancreatography, Endoscopic Retrograde*
Endoscopes
Extremities
Gastrectomy*
Humans

Figure

• 

  Fig. 1 A 58-year-old man who received a total gastrectomy with a Roux-en-Y anastomosis had a 17-mm brown stone removed by single balloon enteroscope (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP). (A) Simple radiography showing the tip of the SBE reaching the end of the afferent loop. (B) The SBE was withdrawn leaving the overtube. (C) An esophagogastroduodenoscope was inserted successfully through the in-dwelling overtube. (D) A cholangiogram showing a diffuse dilatation and a 17-mm filling defect in the common bile duct. Endoscopic papillary dilatation was performed with the controlled radial expansion balloon. (E) The stone was removed using a mechanical lithotripter and a retrieval balloon. (F) An endoscopic nasobiliary drain was inserted and ERCP was completed successfully.

• 

  Fig. 2 A 78-year-old man who received a prior total gastrectomy with a Roux-en-Y anastomosis had small brown stones successfully removed by single balloon enteroscope (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP). (A) The SBE reached the afferent loop. (B) The enteroscope was 80 cm in length. (C) While inserting the esophagogastroduodenoscope, an acute angulation was made 25 cm distal to the overtube. After the collapsed site was dilated by the controlled radial expansion (CRE) balloon, a conventional endoscope could be inserted into the overtube. (D) Endoscopic view; the CRE balloon dilated the acute angulation. (E) Dilatation of the common bile duct was noted on the cholangiogram. (F) Endoscopic papillary dilatation was performed with a CRE balloon. (G) Small brown stones were removed using the retrieval balloon. (H) An endoscopic nasobiliary drainage was inserted and ERCP was completed successfully.

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