Spiral enteroscopy–assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video)

• Published in: Gastrointestinal endoscopy Vol. 87; no. 5; pp. 1241 - 1247
• Main Authors: Ali, Mohammad F., Modayil, Rani, Gurram, Krishna C., Brathwaite, Collin E.M., Friedel, David, Stavropoulos, Stavros N.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.05.2018
• Subjects: Adult; Aged; Ampulla of Vater; Anastomosis, Roux-en-Y; Catheterization; Cholangiopancreatography, Endoscopic Retrograde - methods; Choledocholithiasis - surgery; Cholestasis - surgery; Cohort Studies; Constriction, Pathologic; Endoscopy, Digestive System - methods; Female; Gastrectomy; Gastric Bypass; Humans; Jejunostomy; Liver - surgery; Male; Middle Aged; Retrospective Studies; Sphincter of Oddi Dysfunction - surgery; Sphincterotomy, Endoscopic; Young Adult; DEA-ERCP; RYGB; DBE; IQR; SE-ERCP; EDGE; LA-ERCP
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2017.12.024

Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date. This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success. Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events. With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.