Clin Endosc.  2016 Nov;49(6):510-514. 10.5946/ce.2016.138.

Endoscopic Retrograde Cholangiopancreatography in Bilioenteric Anastomosis

• Park ET

• KMID: 2383445
• DOI: http://doi.org/10.5946/ce.2016.138

Abstract

For diagnosis and treatment of pancreatobiliary diseases, endoscopic retrograde cholangiopancreatography (ERCP) is useful method nowadays and its technically success rate is usually in about 90%-95% of patients with normal gastric and pancreaticobiliary anatomy. Recently ERCP is significantly challenging after intestinal reconstruction, particularly in patients who have undergone pancreaticoduodenectomy (PD, classic Whipple's operation) or pylorus-preserving pancreatoduodenectomy (PPPD) with reconstruction. PD and PPPD relate to numerous techniques have been presented for reconstruction of the digestive tract and pancreaticobiliary tree during the resection bilioenteric stricture commonly occurs later in the postoperative course and developed in 5-year cumulative probability of biliary stricture rate of 8.2% and pancreaticoenteric stricture of 4.6%. This complication was no difference in incidence between patients with benign or malignant disease. In PD or PPPD with reconstruction, short pancreatobiliary limb with biliojejunal anastomosis site is made usually, modestly success rate of intubation to blind loop and cannulation with conventional endoscope. However, in combined Reux-en-Y anastomosis, longer pancreatobiliary limb and additional Reux limb are obstacle to success intubation and cannulation by using conventional endoscope. In this situation, new designed enetroscope with dedicated accessories is efficient.

Keyword

ERCP; Pancreaticoduodenectomy; Pylorus-preserving pancreatoduodenectomy

MeSH Terms

Catheterization
Cholangiopancreatography, Endoscopic Retrograde*
Constriction, Pathologic
Diagnosis
Endoscopes
Extremities
Gastrointestinal Tract
Humans
Incidence
Intubation
Methods
Pancreaticoduodenectomy
Trees

Figure

• 

  Fig. 1. Endoscopic retrograde cholangiopancreatography (ERCP) image obtained using a cap-assisted forward gastroscopy in a patient with pylorus-preserving pancreatoduodenectomy (PPPD) who underwent a hepaticojejunostomy. (A) Endoscopic image of the hepaticojejunal anastomotic stricture site (short arrow). (B) Fluoroscopy image of the reaching to create the hepatojejunal anastomosis (long arrow).

Reference

1. Chahal P, Baron TH, Topazian MD, Petersen BT, Levy MJ, Gostout CJ. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy. 2006; 38:1241–1245.

2. Park BK, Jeon TJ, Jayaraman V, et al. Endoscopic Retrograde Cholangiopancreatography in Patients with Previous Pancreaticoduodenectomy: A Single-Center Experience. Dig Dis Sci. 2016; 61:293–302.

3. Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, Harmsen WS, Farnell MB. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg. 2007; 11:1704–1711.

4. House MG, Cameron JL, Schulick RD, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg. 2006; 243:571–576. discussion 576-578.

5. Demirjian AN, Kent TS, Callery MP, Vollmer CM. The inconsistent nature of symptomatic pancreatico-jejunostomy anastomotic strictures. HPB (Oxford). 2010; 12:482–487.

6. Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001; 136:391–398.

7. Amer S, Horsley-Silva JL, Menias CO, Pannala R. Endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy. Abdom Imaging. 2015; 40:2921–2931.

8. Piessen G, Triboulet JP, Mariette C. Reconstruction after gastrectomy: which technique is best? J Visc Surg. 2010; 147:e273–e283.

9. Moreels TG. Altered anatomy: enteroscopy and ERCP procedure. Best Pract Res Clin Gastroenterol. 2012; 26:347–357.

10. Moreels TG. ERCP in the patient with surgically altered anatomy. Curr Gastroenterol Rep. 2013; 15:343.

11. Moreels TG. Endoscopic retrograde cholangiopancreatography in patients with altered anatomy: How to deal with the challenges? World J Gastrointest Endosc. 2014; 6:345–351.

12. Lee A, Shah JN. Endoscopic approach to the bile duct in the patient with surgically altered anatomy. Gastrointest Endosc Clin N Am. 2013; 23:483–504.

13. Kikuyama M, Itoi T, Ota Y, et al. Therapeutic endoscopy for stenotic pancreatodigestive tract anastomosis after pancreatoduodenectomy (with videos). Gastrointest Endosc. 2011; 73:376–382.

14. Ke S, Ding XM, Gao J, et al. A prospective, randomized trial of Rouxen-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy. Surgery. 2013; 153:743–752.

15. Shimatani M, Takaoka M, Matsushita M, Okazaki K. Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy. Dig Endosc. 2014; 26 Suppl 1:70–78.

16. Ross AS. Endoscopic retrograde cholangiopancreatography in the surgically modified gastrointestinal tract. Gastrointest Endosc Clin N Am. 2009; 19:497–507.

17. Matsushita M, Takakuwa H, Uchida K, Nishio A, Okazaki K. Techniques to facilitate ERCP with a conventional endoscope in patients with previous pancreatoduodenectomy. Endoscopy. 2009; 41:902–906.

18. Farrell J, Carr-Locke D, Garrido T, Ruymann F, Shields S, Saltzman J. Endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy for benign and malignant disease: indications and technical outcomes. Endoscopy. 2006; 38:1246–1249.

19. Tsutsumi K, Kato H, Muro S, et al. ERCP using a short double-balloon enteroscope in patients with prior pancreatoduodenectomy: higher maneuverability supplied by the efferent-limb route. Surg Endosc. 2015; 29:1944–1951.

20. Itokawa F, Itoi T, Ishii K, Sofuni A, Moriyasu F. Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection. Dig Endosc. 2014; 26 Suppl 2:136–143.

21. Mönkemuller K, Jovanovic I. Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures: A practical classification. World J Gastrointest Endosc. 2011; 3:213–219.

22. Kinney TP, Li R, Gupta K, et al. Therapeutic pancreatic endoscopy after Whipple resection requires rendezvous access. Endoscopy. 2009; 41:898–901.

23. Park JH, Ye BD, Byeon JS, et al. Approaching pancreatic duct through pancreaticojejunostomy site with double ballon enteroscope in patients with Roux-en-Y anatomy. Hepatogastroenterology. 2013; 60:1753–1758.

24. Cho S, Kamalaporn P, Kandel G, Kortan P, Marcon N, May G. ‘Short’ double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract. Can J Gastroenterol. 2011; 25:615–619.

25. Shimatani M, Matsushita M, Takaoka M, et al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy. 2009; 41:849–854.

26. Siddiqui AA, Chaaya A, Shelton C, et al. Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study. Dig Dis Sci. 2013; 58:858–864.

27. Shah RJ, Smolkin M, Yen R, et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013; 77:593–600.

28. De Koning M, Moreels TG. Comparison of double-balloon and single-balloon enteroscope for therapeutic endoscopic retrograde cholangiography after Roux-en-Y small bowel surgery. BMC Gastroenterol. 2016; 16:98.