Innovations and techniques for balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine. Recently, many studies have reported that balloon-enteroscope-assisted ERCP (BEA-ERCP) is a safe and effective procedure. However, further improvements in outcomes and the development of simplified procedures are required. Percutaneous treatment, Laparoscopy-assisted ERCP, endoscopic ultrasound-guided anterograde intervention, and open surgery are effective treatments. However, treatment should be noninvasive, effective, and safe. We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications. BEA-ERCP still requires high expertise-level techniques and is far from a routinely performed procedure. Various techniques have been proposed to facilitate scope insertion (insertion with percutaneous transhepatic biliary drainage (PTBD) rendezvous technique, Short type single-balloon enteroscopes with passive bending section, Intraluminal injection of indigo carmine, CO2 inflation guidance), cannulation (PTBD or percutaneous transgallbladder drainage rendezvous technique, Dilation using screw drill, Rendezvous technique combining DBE with a cholangioscope, endoscopic ultrasound-guided rendezvous technique), and treatment (overtube-assisted technique, Short type balloon enteroscopes) during BEA-ERCP. The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients. A standard procedure for ERCP yet to be established for patients with a reconstructed intestine. At present, BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as first-line treatment. In this article, we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.

A Case Series: Outcomes of Endoscopic Biliary Self-Expandable Metal Stent for Malignant Biliary Obstruction with Surgically Altered Anatomy

“…Since the development of short-type balloon enteroscopes, the outcomes of lithotripsy and endoscopic biliary drainage (EBD) using a plastic stent in such patients are now non-inferior to those of conventional ERCP, provided that cannulation is successfully performed [1][2][3][4][5].…”

Endoscopic Retrograde Cholangiopancreatography in Post Gastrectomy Patients

“…Therefore, the cap is very useful for overcoming the sharp angulations and searching the opening of the ampulla of Vater [7,16]. Finally, applying abdominal compression as needed can help in intubating the scope [22]. In summary, for successful intubation to the ampulla of Vater in post-gastrectomy patients, (1) the use of indigocarmine and carbon dioxide, (2) fluoroscopic guidance, (3) a transparent cap, and (4) manual abdominal compression are essential prerequisites.…”

Endoscopic treatment for distal malignant biliary obstruction

“…Despite this, while it has been shown that PS are cheaper than metal stents, metal stents have better drainage and longer patency (11), and recent data shows that they are cost-effective (12,13). Also we can perform EBD for intact papilla in patients with an altered anatomy by using balloon-enteroscopyassisted ERCP (BEA-ERCP) (14)(15)(16)(17).…”