Int J Gastrointest Interv 2022; 11(1): 5-12
Published online January 31, 2022 https://doi.org/10.18528/ijgii210058
Copyright © International Journal of Gastrointestinal Intervention.
Yuki Tanisaka *, Masafumi Mizuide , Akashi Fujita , Tomoya Ogawa , Hiromune Katsuda , Yoichi Saito , Kazuya Miyaguchi , Ryuhei Jinushi , Rie Terada , Yuya Nakano , Tomoaki Tashima , Yumi Mashimo , and Shomei Ryozawa
Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
Correspondence to:* Department of Gastroenterology, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama 350-1298, Japan.
E-mail address: firstname.lastname@example.org (Y. Tanisaka).
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosis and intervention in patients with biliopancreatic disorders. However, ERCP in patients with surgically altered anatomy (SAA) is considered more difficult than in patients with normal anatomy. Since the introduction of balloon enteroscopes for patients with small intestine disorders, single-balloon enteroscopes (SBEs) and double-balloon enteroscopes (DBEs) have also been used for biliopancreatic diseases in patients with SAA. Nevertheless, the use of conventional SBEs and DBEs is limited, as a balloon enteroscope has a working length of 200 cm and a narrow working channel with a diameter of 2.8 mm; therefore, few ERCP accessories are available for use. A short-type SBE with a working length of 152 cm and a working channel of 3.2 mm in diameter, and a short-type DBE with a working length of 155 cm and a working channel of 3.2 mm were introduced to solve these difficulties. Favorable outcomes of these devices have recently been reported. Moreover, studies have reported several tips to achieve procedural success and factors affecting procedure failure. Difficult cases necessitate alternative techniques, such as percutaneous transhepatic biliary drainage and endoscopic ultrasound-guided biliary drainage.
Keywords: Double-balloon enteroscopy, Endoscopic retrograde cholangiopancreatography, Endosonography, Single-balloon enteroscopy
Since its development in 1968, endoscopic retrograde cholangiopancreatography (ERCP) has been considered the gold standard for diagnosis and intervention in biliopancreatic diseases.1 Studies published over 15 years ago reported that ERCP-related procedures were successful in around 95% of cases.1,2 However, ERCP-related procedures are quite difficult to perform using a conventional duodenoscope in patients with surgically altered anatomy (SAA) due to procedures such as Roux-en-Y gastrectomy, hepaticojejunostomy with Roux-en-Y, pancreaticoduodenectomy, or Billroth II gastrectomy. The presence of a long, tortuous afferent limb and adhesions makes it difficult to reach the target site (such as the papilla or hepaticojejunal anastomosis). Even after reaching the target site, selective cannulation and subsequent treatments, such as stone extraction or drainage, are more technically demanding in patients with SAA than in those with normal anatomy. Therefore, percutaneous transhepatic biliary drainage (PTBD) or surgical drainage were preferred in such cases.3,4
Since the introduction of the balloon enteroscope (BE) for small bowel disorders,5 balloon-assisted ERCP, such as single-balloon enteroscope (SBE)-assisted ERCP, or double-balloon enteroscope (DBE)-assisted ERCP, has been used in patients with SAA. Nevertheless, the use of conventional SBE and DBE has been limited since BEs have a long working length (200 cm) and a narrow working channel (2.8 mm in diameter); therefore, few ERCP accessories are available for use and scope exchange is generally needed.
A short-type SBE (short SBE) with a working length of 152 cm and a working channel of 3.2 mm in diameter and a short-type DBE (short DBE) with a working length of 155 cm and a working channel of 3.2 mm have been introduced to solve these difficulties. These scopes have made it possible to perform various procedures. Moreover, studies have reported factors that can help achieve procedural success and factors that increase the risk of procedure failure. In this review, we discuss recent advances in BE-assisted ERCP in patients with SAA.
A BE is advanced by holding and shortening the intestine with an inflated balloon while confirming the fluoroscopy findings. Two types of BEs are currently available: SBEs and DBEs. The difference between SBEs and DBEs is the number of balloons (Fig. 1). Table 1 lists the specifications of the SBEs and DBEs that are currently available. An SBE is equipped with one balloon, which is attached to the tip of the over-tube. In contrast, a DBE is equipped with two balloons. One is attached to the tip of the endoscope, while the other is attached to the tip of the over-tube. Moreover, the working channel port of an SBE appears in the 8-o’clock direction on the endoscopic screen. In contrast, it appears in the 5:30-o’clock direction for a DBE. Since both conventional SBEs and DBEs have a working length of 200 cm, only a few ERCP accessories are available for use. Therefore, scope exchange from BE to a conventional forward-viewing upper endoscope while leaving the over-tube after reaching the target site may be needed.6 Moreover, the working channel diameter of 2.8 mm in a conventional SBE also makes it difficult to use ERCP accessories and perform advanced techniques, such as the double-guidewire technique. According to the latest systematic review and meta-analysis, the total procedural success rate using conventional SBE was 72.7%.7 Recently, a short SBE and DBE, with a working length of 152 cm (short SBE) and 155 cm (short DBE), and with working channel diameters of 3.2 mm have become available, making it possible to use a wider range of accessories during BE-assisted ERCP. Furthermore, the short SBE is equipped with passive bending and high-force transmission,8 while the short DBE permits adaptive bending and advanced force transmission.9 These features have contributed to overcoming the difficulties associated with scope insertion to the target site or performing the subsequent procedures. When using a short SBE, if the scope is at the intestinal tract wall when passing through a sharp flexure, the passive bending section allows the scope to bend along the curve of the intestinal wall, making it possible to move forward smoothly. High-force transmission makes it possible to perform torque operations efficiently and provides better scope control. Therefore, it is also useful for selective cannulation and subsequent procedures. When using a short DBE, adaptive bending and advanced force transmission play a role similar to passive bending and high-force transmission with a short SBE.
Table 1 . Specifications of SBEs and DBEs.
|SIF-Q260 (SBE)||SIF-H290S (SBE)||EN-580T (DBE)||EI-580BT (DBE)|
|Field of view (degrees)||140||140||140||140|
|Outer diameter (mm)||9.2||9.2||9.4||9.4|
|Working length (mm)||2,000||1,520||2,000||1,550|
|Working channel diameter (mm)||2.8||3.2||3.2||3.2|
|Advanced force transmission||No||No||No||Yes|
SBE, single-balloon enteroscopy; DBE, double-balloon enteroscopy..
In general, ERCP-related procedures using BE are performed with the patient under conscious sedation (e.g., using intravenous midazolam and pethidine). During scope insertion, the patient is placed in the prone position, but in cases of difficult insertion, the patient’s position is modified or abdominal pressure is applied. Following the insertion of a BE into the small intestine while forming a loop, the small intestine can be fixed with the balloon and shortened or straightened while observing fluoroscopy. The use of carbon dioxide has been recognized as a technical improvement for endoscope insertion. Some difficult cases, such as those with long afferent limbs as seen in Roux-en-Y reconstruction cases, necessitate changing from a short-type enteroscope to a long-type enteroscope because of the insufficient length of the short-type enteroscope.10 A transparent hood is useful both for scope insertion and for subsequent procedures such as biliary cannulation.11 Since postoperative adhesions tend to occur in patients with SAA, endoscopists can feel the adhesions during scope insertion or shortening. It must be considered that perforation can occur more frequently during scope insertion in patients with SAA compared to patients with normal anatomy. After reaching the target site, selective cannulation is performed by advancing the guidewire while injecting the contrast medium to confirm its direction. After selective cannulation and cholangiopancreatography, endoscopic diagnoses or interventions, such as stone extraction, balloon dilation of the hepaticojejunostomy or pancreaticojejunostomy anastomosis, stent placement, and biopsy or cytology for diagnosis, are performed.
Endoscopic sphincterotomy (EST) is a common procedure during ERCP in patients with normal anatomy. However, it can be challenging in patients with SAA (after Billroth II gastrectomy or Roux-en-Y gastrectomy). It is considered difficult because the correct direction of the incision is sometimes uncertain due to the inverted position in these patients; if the incision is made in the wrong direction, perforation can occur. A study from a tertiary referral endoscopy center evaluated 40 cases of endoscopic papillary large balloon (> 10 mm) dilation (EPLBD) without EST for stone extraction in patients who had undergone Billroth II gastrectomy. The stones were successfully removed in all cases. The acute complications from EPLBD included mild pancreatitis in two patients (5.0%).12 This result shows the usefulness and safety of EPLBD without EST. If endoscopists find it difficult to perform EST in patients with a history of Billroth II gastrectomy or Roux-en-Y gastrectomy, EPLBD without EST may be recommended.
Table 2 shows the outcomes of conventional or short SBE-assisted ERCP procedures in patients with SAA.6,10,11,13–18 The success of enteroscopy is indicated by the successful insertion of the scope to the target site. The procedural success rates for conventional and short SBE-assisted ERCP, which indicate the rates of successful completion of all steps, were 57.7%–76.9% and 70.4%–85.9%, respectively. It seems that the outcomes were better with short SBEs than with conventional SBEs. A recent multicenter retrospective study of 1,318 patients reported that the enteroscopy, cannulation, and procedural success rates were 87.9%, 87.0%, and 74.9%, respectively. Adverse events occurred in 7.7% of patients.19 A systematic review and meta-analysis that was mentioned previously reported that the pooled enteroscopy, cannulation, and procedural success rates were 86.6%, 90%, and 75.8%, respectively. Adverse events occurred in 6.6% of the procedures.7 Various procedures, such as metallic stent placement, were performed using short SBEs (Fig. 2).20,21
Table 2 . Outcomes of SBE-Assisted ERCP.
|Author||Year||Type of scope||Enteroscopy success||Cannulation success||Procedural success|
|Itoi et al6||2010||Conventional||92.3 (12/13)||83.3 (10/12)||76.9 (10/13)|
|Wang et al13||2010||Conventional||81.3 (13/16)||92.3 (12/13)||75.0 (12/16)|
|Azeem et al14||2013||Conventional||91.4 (53/58)||83.0 (44/53)||75.9 (44/58)|
|Lenze et al15||2014||Conventional||73.1 (19/26)||78.9 (15/19)||57.7 (15/26)|
|Trindade et al11||2015||Conventional||87.5 (49/56)||89.8 (44/49)||71.4 (40/56)|
|Kawamura et al16||2015||Short||88.9 (24/27)||83.3 (20/24)||70.4 (19/27)|
|Yamauchi et al17||2015||Short||90.5 (76/84)||89.5 (68/76)||77.4 (65/84)|
|Yane et al18||2017||Short||92.6 (188/203)||N/A||81.8 (166/203)|
|Tanisaka et al10||2019||Short||94.8 (181/191)||92.3 (167/181)||85.9 (164/191)|
Values are presented as % (number)..
SBE, single-balloon enteroscopy; ERCP, endoscopic retrograde cholangiopancreatography; N/A, not available..
Several strategies are used to ensure the success of SBE-assisted ERCP. For scope insertion to the target site, as mentioned before, a change from a short SBE to a conventional SBE is useful in cases with long afferent limbs, such as in patients who have undergone Roux-en-Y reconstruction. Selective cannulation is considered to be more difficult in patients with SAA than in those with normal anatomy. Possible reasons are that the papilla appears inverted, the view of the papilla tends to be tangential, the SBE is forward-viewing, and an elevator system is not present. As previously mentioned, the use of a transparent hood is effective for biliary cannulation.11 It has been reported that using the retroflex position helps to obtain a better view of the papilla in patients with Roux-en-Y gastrectomy.22,23 To achieve the retroflex position, the enteroscope is advanced while using the upper angle at the inferior duodenal angle. The scope provides a J-turn form (Fig. 3). Furthermore, various techniques, such as the double-guidewire method, insertion along the pancreatic duct stent,24 and the use of a unique cannula equipped with a double lumen,25 have been reported to be useful.
Several studies have analyzed factors affecting the procedural results of SBE-assisted ERCP. One study reported that pancreatic indications, the first ERCP attempt, and the absence of a transparent hood affected procedural failure.18 Another study claimed that malignant biliary obstruction, the first ERCP attempt, and Roux-en-Y reconstruction affected the procedural results.10 Similarly, a multicenter study reported that the factors that affected procedural failure were malignancy, pancreatic indication, and Roux-en-Y reconstruction.19
Table 3 shows the outcomes of conventional/short DBE-assisted ERCP procedures in patients with SAA.26–34 The procedural success rates of conventional and short DBE-assisted ERCP were 80.0%–88.0% and 69.8%–98.6%, respectively. A multicenter prospective study of 311 patients reported that the enteroscopy, cannulation, and procedural success rates were 97.7%, 96.4%, and 92.3%, respectively. Adverse events occurred in 10.6% of patients.35 According to the latest systematic review and meta-analysis, the pooled enteroscopy, cannulation, and procedural success rates were 90%, 94%, and 93%, respectively. Adverse events occurred in 4% of the procedures.36 Major adverse events included pancreatitis (
Table 3 . Outcomes of DBE-Assisted ERCP.
|Author||Year||Type of scope||Enteroscopy success||Cannulation success||Procedural success|
|Aabakken et al26||2007||Conventional||94.4 (17/18)||88.2 (15/17)||83.3 (15/18)|
|Emmett and Mallat27||2007||Conventional||85.0 (17/20)||94.1 (16/17)||80.0 (16/20)|
|Pohl et al28||2009||Conventional||88.0 (22/25)||100 (22/22)||88.0 (22/25)|
|Shimatani et al29||2009||Short||97.1 (100/103)||98.0 (98/100)||95.1 (98/103)|
|Parlak et al30||2010||Conventional||92.9 (13/14)||100 (13/13)||85.7 (12/14)|
|Tsutsumi et al31||2015||Short||98.6 (71/72)||100 (71/71)||98.6 (71/72)|
|Cheng et al32||2015||Short||94.8 (73/77)||94.5 (69/73)||87.0 (67/77)|
|Liu et al33||2017||Short||75.6 (65/86)||92.3 (60/65)||69.8 (60/86)|
|Uchida et al34||2020||Short||94.3 (759/805)||N/A||90.7 (730/805)|
Values are presented as % (number)..
DBE, double-balloon enteroscopy; ERCP, endoscopic retrograde cholangiopancreatography; N/A, not available..
Several suggestions have been made for ensuring the successful completion of DBE-assisted ERCP. Similar to procedures using an SBE, the retroflex position is also useful for biliary cannulation using a DBE. Since the working channel port appears in the 5:30-o’clock position in the endoscopic view, positioning the papilla in the 6-o’clock direction is effective for performing EST safely.38 This position provides total protrusion and a hooding fold, which are the landmarks for the correct direction of the bile duct while performing EST. Furthermore, it is possible to confirm whether common bile duct stones are present between the balloon and common bile duct during EPLBD.39
Factors affecting the procedural results of DBE-assisted ERCP have also been reported. A study reported that DBE-assisted ERCP in patients with childhood surgery, biliary atresia, and a second operation post-transplant was likely to fail among those who had undergone Roux-en-Y reconstruction.33 Another study showed that Roux-en-Y reconstruction and first-time DBE-assisted ERCP affected the technical failure and adverse event rates.34 In that study, whether the procedure was performed by a trainee did not significantly affect the technical success or adverse event rates. Moreover, a study that analyzed the factors affecting complete stone extraction revealed that a larger common bile duct diameter had a negative effect on complete stone extraction, while using the retroflex position could be useful for achieving complete stone clearance.40
Although many reports on BE-assisted ERCP have shown good outcomes in patients with SAA, there are several difficulties in achieving successful completion; therefore, it is impossible to complete treatment in all cases using BE-assisted ERCP only, and alternative treatments are needed in some patients. PTBD is an effective drainage technique that is performed under fluoroscopic guidance to gain biliary access. A needle is passed through the skin into a dilated biliary duct, after which the patient may undergo external drainage.41 Despite high success rates, it may be impractical in urgent cases because of the requirement for serial dilation and track maturation.42 Moreover, there may be problems associated with the external drainage tube. However, PTBD can be used to perform stone extraction effectively and safely. Consequently, it is a good choice as an alternative treatment in cases of difficult stone extraction using BE.
In recent years, interventional endoscopic ultrasound (EUS) has been attracting attention as an alternative treatment for patients who have experienced ERCP failure (e.g., failure of scope insertion or biliary cannulation). Interventional EUS may be a first-line treatment in some cases, such as patients with malignant tumors with cancer invasion of the small intestine or papilla.10 Several drainage methods exist for interventional EUS in patients with SAA:43 (1) EUS-guided hepaticogastrostomy (EUS-HGS), (2) EUS-guided anterograde stenting (EUS-AS), and (3) EUS-guided rendezvous procedure (EUS-RV). The stomach is punctured in EUS-HGS. When the stomach has been resected, such as in Roux-en-Y gastrectomy cases, the puncture is performed from the jejunal limb. After cholangiography and guidewire insertion, the fistula is dilated using a dilation device followed by the placement of a biliary stent.44 Fig. 4 shows successful EUS-HGS in a patient with SAA. In EUS-AS, after puncture of the bile duct, a guidewire is passed through the papilla, and a biliary stent is placed via an antegrade route.45 EUS-RV is a suitable option for difficult cannulation cases. After puncture of the bile duct, the guidewire is directed beyond the papilla. As a result, the guidewire is positioned in the duodenum. Afterward, the scope is exchanged from the duodenoscope. The guidewire is grasped using a forceps device and pulled into the working channel. Finally, biliary cannulation through the papilla is successfully completed.46
Table 4 shows the outcomes of EUS-guided biliary drainage (EUS-BD).47–55 According to the latest systematic review and meta-analysis, the pooled technical success rates and clinical success rates were 91.5% and 87%, respectively. Adverse events occurred in 17.9% of patients. The main adverse events were bile leakage (4.1%), stent migration (3.9%), and infections (3.8%).56 Although interventional EUS had high success rates, adverse events were more frequent than with BE-assisted ERCP.
Table 4 . Outcomes of EUS-BD.
|Author||Year||Technical success||Clinical success||Adverse events|
|Hara et al47||2011||94.4 (17/18)||100 (17/17)||16.7 (3/18)|
|Shah et al48||2012||70.5 (62/88)||70.5 (62/88)||6.8 (6/88)|
|Khashab et al49||2013||94.3 (33/35)||91.4 (32/35)||11.4 (4/35)|
|Kawakubo et al50||2014||95.3 (61/64)||N/A||18.8 (12/64)|
|Gupta et al51||2014||88.5 (207/234)||N/A||34.6 (81/234)|
|Kunda et al52||2016||98.2 (56/57)||94.7 (54/57)||7.1 (4/56)|
|Kahaleh et al53||2016||91.4 (32/35)||88.6 (31/35)||25.7 (9/35)|
|Tsuchiya et al54||2018||100 (19/19)||94.7 (18/19)||36.8 (7/19)|
|Minaga et al55||2019||85.2 (46/54)||85.2 (46/54)||18.5 (10/54)|
Values are presented as % (number)..
EUS-BD, endoscopic ultrasound-guided biliary drainage; N/A, not available..
Several reports have compared BE-assisted ERCP and EUS-BD in patients with SAA. A multicenter retrospective study reported that the clinical success rates of BE-assisted ERCP and EUS-BD were 59.1% and 88%, respectively (
In this review, we discussed recent advances in BE-assisted ERCP in patients with SAA. Many studies have demonstrated the usefulness and safety of BE-assisted ERCP. Recommendations to achieve procedural success and factors affecting the procedural results have been reported. In difficult cases, alternative techniques, such as PTBD and EUS-BD, are required.
No potential conflict of interest relevant to this article was reported.
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