Int J Gastrointest Interv 2023; 12(3): 115-122
Published online July 31, 2023 https://doi.org/10.18528/ijgii230006
Copyright © International Journal of Gastrointestinal Intervention.
Department of Gastroenterology, Hepatology & Nutrition, MD Anderson Cancer Center, Houston, TX, USA
Correspondence to:*Department of Gastroenterology, Hepatology & Nutrition, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
E-mail address: email@example.com (J.H. Lee).
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.
Background: Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography (ERCP). While ERCP maintains a success rate of 90% to 95% in patients with native anatomy, the data are less robust for patients with post-pancreaticoduodenectomy (PD) anatomy. We conducted a retrospective analysis of the technical success (TS) and clinical success (CS) rates of ERCP in post-PD patients. In addition, we describe our experience using novel rigidizing overtubes to facilitate post-PD ERCP.
Methods: Patients with PD referred to our institution between 2006 and 2021 for ERCP were included. Major outcomes included the TS rate (successful biliary intervention) and the CS rate (improvement in patient symptomatology with or without normalization of bilirubin levels).
Results: In total, 47 patients underwent 102 ERCPs for biliary (n = 98) and pancreatic (n = 4) indications. The overall TS and CS rates were 82.4% and 75.5%, respectively. Rigidizing overtubes were utilized in 5 patients who underwent 11 ERCPs, with TS and CS rates of 90.9% and 90.9%, respectively. The overall adverse event rate was 4.9%, with no adverse events noted in cases with rigidizing overtubes.
Conclusion: Despite the challenges in ERCP in patients with surgically altered anatomy, this retrospective analysis demonstrates a moderately high TS rate with minimal adverse events. A rigidizing overtube may be utilized to improve TS and CS in patients with post-surgical anatomy.
Keywords: Carcinoma, pancreatic ductal, Cholangiopancreatography, endoscopic retrograde, Endoscopy, gastrointestinal, Pancreatic neoplasms, Pancreaticoduodenectomy
Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP). Patients are frequently encountered in clinical practice with a history of the following surgical procedures that affect ERCP success: Billroth II, Roux-en-Y gastric bypass, Roux-en-Y hepaticojejunostomy and pancreaticoduodenectomy (PD; Whipple procedure). With respect to PD, immense surgical improvements have led to significantly decreased mortality. However, postoperative morbidity is still present in many cases, including complications such as biliary stricture, pancreaticocutaneous fistula, and delayed gastric emptying.1–3 As the Whipple procedure has become more routine in the management of benign and malignant conditions, the need for endoscopic therapeutic interventions has grown in tandem.
Patients with post-PD anatomy can present with pancreaticobiliary symptoms stemming from changes in their anatomy, in addition to common pathologies including choledocholithiasis. Obstructive jaundice can occur from recurrent disease or surgical bilioenteric anastomotic strictures. Prior studies have demonstrated that 2.6% of patients develop bilioenteric strictures within 13 months, and 8.2% in 5 years.3,4 Likewise, recurrent pancreatitis or abdominal pain can occur from a stricture of the pancreatic duct or pancreaticojejunal anastomosis. However, endoscopic management and evaluation with ERCP can be challenging. The difficulties in performing endoscopy are not only related to navigating through altered anatomy, but also to the lack of devices specifically designed for post-surgical anatomy.5,6 Several techniques have been attempted to improve the success of pancreaticobiliary interventions. Most notably, single-balloon enteroscopy, double-balloon enteroscopy, and rotational overtubes have been utilized to improve post-Whipple ERCP technical success.7–11 In addition, endoscopic ultrasound (EUS)-guided therapies including EUS-pancreatic duct drainage (EUS-PDD) and EUS-enteroenterostomy have been described as possible solutions to assist in ERCP.12–16
Although ERCP maintains a success rate of 90% to 95% in patients with native gastric and pancreaticoduodenal anatomy, the data are less robust in patients with post-PD anatomy.17,18 Moreover, the use of a rigidizing overtube in ERCP has not been well described as an adjunctive device in post-surgical anatomy.19 In this study, a retrospective analysis was conducted to evaluate the technical success rate, clinical success rate, reasons for failure, and adverse events in post-PD patients undergoing ERCP with and without a rigidizing overtube.
This was a retrospective study performed at MD Anderson Cancer Center between 2006 and 2021. The protocol (RCR05-0672) was approved by the institutional review board.
Patients who had undergone PD (Whipple’s procedure) and required ERCP were included. Electronic medical records were used to capture pertinent demographic information, oncologic history, indications for PD, biochemical data, and follow-up information. ERCP procedural reports were analyzed for the indication, selection of the endoscope used, primary anastomosis evaluated, stricture location, treatment for the stricture, and stent characteristics. Each procedure was included as a separate entry for patients who received multiple ERCPs. A Pathfinder (Neptune Medical) rigidizing overtube was used as an adjunctive device in a subset of cases.
The major outcomes were the technical and clinical success rates. The technical success rate was defined as the ability to perform an intended therapeutic intervention, including the evaluation of a stricture, stent placement, and stent removal. The clinical success rate was defined as a documented improvement of bilirubin to normal or 50% of the peak value within 4 weeks. The clinical success rate was not calculated for pancreatic indications. The additional outcomes evaluated included the reasons for technical failure and an analysis of the adverse events.
Descriptive statistics were used to characterize the demographic and clinical characteristics of the study population. The statistical analysis was performed using Stata/SE version 16.0 statistical software (Stata Corp.).
In total, 102 ERCPs were performed in 47 patients with prior PD. Within this sample, there were 31 male (66.0%) and 16 female (34.0%) patients. The patients’ mean age was 61.5 years of age. The indication for PD in the majority of patients was pancreatic adenocarcinoma (
Table 1 . Patient Characteristics.
|Age (yr)||61.5 ± 11.6|
|Sample size (||47|
|Pancreatic adenocarcinoma||26 (55.3)|
|Pancreatic neuroendocrine tumor||5 (10.6)|
|Ampullary adenocarcinoma||4 (8.5)|
|Ampullary adenoma||1 (2.1)|
|Ampullary neuroendocrine tumor||1 (2.1)|
|Duodenal adenocarcinoma||2 (4.3)|
|Duodenal adenoma with high grade dysplasia||1 (2.1)|
|Duodenal neuroendocrine tumor||1 (2.1)|
|Intraductal papillary mucinous neoplasm||3 (6.4)|
|Mucinous cystic neoplasm||1 (2.1)|
|Metastatic renal cell carcinoma||1 (2.1)|
|No neoadjuvant therapy||25 (53.2)|
Among the 102 procedures, there were 98 biliary and 4 pancreatic indications for ERCP, the majority of which included obstructive jaundice (
Table 2 . Procedure Characteristics.
|Total procedures (||102|
|Obstructive jaundice||22 (21.6)|
|Ductal dilation||4 (3.9)|
|Evaluation of stricture||5 (4.9)|
|Stent evaluation||30 (29.4)|
|Elevated liver enzymes||1 (1.0)|
|Endoscope used for successful interventions|
|Adult colonoscope||20 (23.8)|
|Pediatric colonoscope||15 (17.9)|
|Therapeutic upper endoscope||30 (35.7)|
|Upper endoscope||2 (2.4)|
|Not specified||16 (19.0)|
|Indicated cannulations (adjusted after anastomosis identification)||89 (87.3)|
|Cholangiograms and pancreaticograms conducted||90 (88.2)|
|Choledochojejunal stricture||51 (57.3)|
|Common hepatic stricture||2 (2.2)|
|Hilar stricture||2 (2.2)|
|Intrahepatic stricture||6 (6.7)|
|No stricture||28 (31.5)|
|No stricture||1 (100.0)|
|Uncovered metal||4 (7.3)|
|Covered metal||2 (3.6)|
Among all patients, 90 (88.2%) patients had cholangiograms (
Table 3 . Stricture Types and Stents Utilized.
|Stricture type||Plastic||Covered metal||Uncovered metal|
The technical success rate for ERCP in post-PD patients was 82.4% (84/102). Biliary procedures had a technical success rate of 84.7% (83/98), whereas pancreatic procedures had a technical success rate of 25.0% (1/4). The clinical success rate was 75.5% (74/98). Failure of biliary interventions mostly occurred secondary to the inability to reach or visualize the anastomosis (
Table 4 . Overall Technical and Clinical Success.
|Overall technical success|
|Biliary and pancreatic procedures||102|
|Overall biliary technical success|
|Overall pancreatic technical success|
|Overall clinical success|
|Pathfinder technical success|
|Pathfinder clinical success|
Pathfinder rigidizing overtubes were utilized in 11 ERCPs and 5 patients. The indications included stent evaluation, including removal, insertion, or exchange (
Table 5 . Procedure Characteristics (Pathfinder).
|Total procedures||11 (10.8)|
|Obstructive jaundice||3 (27.3)|
|Ductal dilation||0 (0.0)|
|Evaluation of stricture||2 (18.2)|
|Stent evaluation||5 (45.5)|
|Elevated liver enzymes||0 (0.0)|
|Endoscope used for procedure||11|
|Adult colonoscope||3 (27.3)|
|Pediatric colonoscope||0 (0.0)|
|Therapeutic upper endoscope||6 (54.5)|
|Upper endoscope||0 (0.0)|
|Not specified||2 (18.2)|
|Choledochojejunal stricture||9 (81.8)|
|Common hepatic stricture||0 (0.0)|
|Hilar stricture||0 (0.0)|
|Intrahepatic stricture||1 (9.1)|
|No stricture||1 (9.1)|
|Uncovered metal||0 (0.0)|
|Covered metal||0 (0.0)|
There were 5 (4.9%) adverse events in the 102 procedures. There were three cases of fever, and one case of cholangitis, all of which resolved either with supportive care or antibiotics. One patient had post-procedure nausea and abdominal pain, which resolved with supportive management. No additional procedure-related adverse events occurred, including bleeding, perforation, pancreatitis, the need for surgical intervention, or death following ERCP. In addition, there were no procedure-related adverse events in patients in whom rigidizing overtubes were utilized.
A retrospective analysis of 47 patients undergoing 102 ERCPs post-PD demonstrated an overall technical success rate of 82.4% and clinical success rate of 75.5%. Rigidizing overtubes were utilized in a subgroup of patients with a technical success rate of 90.9% and clinical success rate of 90.9%. The overall adverse event rate was 4.9%, and most adverse events were mild (self-resolving fevers). Therefore, ERCP is a safe and effective therapeutic procedure in post-PD anatomy for biliary intervention. The use of a rigidizing overtube may enhance technical and clinical success in ERCP; however, additional studies need to be undertaken for further evaluation.
In a review of the literature, our biliary technical success rate was similar to that reported by Chahal et al.17 In comparison to the study of Chahal et al,17 in which most procedures were conducted with duodenoscopes, our procedures were conducted mainly with therapeutic upper endoscopes, adult colonoscopes, and pediatric colonoscopes with similar success. Chahal et al17 reported two adverse events: one medically managed retroperitoneal perforation and one self-resolving Mallory Weiss tear. The increased rate of perforation is a well-described adverse event of side-viewing endoscopes, and as such, the utilization of duodenoscopes was limited in our sample. Despite the use of forward-viewing endoscopes, similar technical success was achieved.
In our study, biliary cannulation was highly successful (97.7%) if the choledochojejunostomy was identified. Most failed biliary ERCPs were related to an inability to visualize or navigate the endoscope to the level of the anastomosis. Advancement of the endoscope to the choledochojejunostomy can be challenging. It requires accurate identification of the afferent limb and traversal to the anastomotic site. Post-PD anatomy encourages acute bowel angulation and loop formation, making it difficult to advance to the choledochojejunostomy site (Fig. 1, 2). Moreover, the limited visibility of a side-viewing scope, decreased flexibility, and larger caliber duodenoscope hinders the traversal of the endoscope to the anastomosis and heightens the risk for perforation. To mitigate some of the anatomic challenges of post-PD anatomy, a novel finding in this study related to the use of Pathfinder rigidizing overtubes in a subgroup of patients requiring ERCP. Rigidizing overtubes can dynamically rigidize and transform between a flexible and rigid state, which can straighten acute angulations, prevent loop formation, and stabilize endoscopes for therapeutic intervention (Fig. 3–5). Based on this limited sample, rigidizing overtubes can be a safe and effective adjunctive tool in reaching the choledochojejunostomy site and facilitating successful cannulation in patients with post-PD anatomy. Most studies have cited the successful use of rigidizing overtubes in difficult colonoscopies, but the literature has been sparse in demonstrating its use in ERCP, especially in patients with altered anatomy.19 Prior studies have demonstrated the use of rotational overtubes without dynamic rigidization in facilitating ERCP in patients with surgically altered anatomy.7 The overall success rate of ERCP performed with rotational overtubes reported in the literature was lower (65%) than that observed for dynamic rigidizing overtubes (90.9%) in our sample. However, additional studies assessing the efficacy of rigidizing overtubes in ERCP are required before further conclusions can be drawn given the small size of our sample.
Device-assisted enteroscopy has emerged as the leading modality for reaching the enterobiliary anastomosis and facilitating ERCP in patients with surgically altered anatomy.6,8–10 However, both single-balloon and double-balloon enteroscopes have longer working lengths and smaller working channels, which preclude the utilization of standard ERCP devices and larger caliber stents. Contrastingly, colonoscopes and short double-balloon enteroscopes can provide additional length while maintaining compatibility with some devices and allow larger caliber stent placement, but lack an elevator for therapeutic intervention. More recently, EUS-guided enteroenterostomy has emerged as a possible solution to reaching the anastomotic site that may enable appropriate device utilization with a standard duodenoscope and facilitate cannulation with an elevator.12,15,20 In addition, the use of rigidizing overtubes, as demonstrated in this study, may allow adequate access to the anastomotic site for biliary intervention.19
Our sample furnished limited data on the endoscopic evaluation and management of the pancreas in post-PD anatomy. However, prior literature has demonstrated limited technical success in post-PD patients.17,18 Similar technical limitations in traversing the afferent limb are heightened in pancreatic evaluations given the longer length of the afferent limb that is required to reach the pancreaticojejunostomy. This has led to the development of EUS-guided pancreatic interventions, including enteroenterostomy, anterograde stenting, and the rendezvous technique. A recent study compared the safety and efficacy of EUS-PDD and enteroscopy-assisted endoscopic retrograde pancreatography (e-ERP) for the management of pancreatic-related adverse events in patients with post-PD anatomy.16 EUS-PDD had a higher technical success rate than e-ERP (92.5% vs. 20%). However, there were significantly more adverse events in patients who received EUS-PDD than in those who received e-ERP (35% vs. 2.9%). While improvements are necessary to reduce the occurrence of procedure-related adverse events when performing EUS-PDD, it is emerging as a promising alternative to the traditional methods of pancreatic management in the post-PD population.
A limitation of this study is that it was a retrospective analysis conducted at a single tertiary care center. The study was also limited by a relatively small number of patients. Although there were a larger number of total ERCPs than in prior studies, some patients received multiple ERCPs. Patients with prior interventions including stent placement may serve as a roadmap for identification of choledochojejunal anastomosis, facilitating a subsequent successful intervention. As a result, the number of repeated ERCPs may have biased our technical success rate. In addition, as a large comprehensive cancer center, post-surgical anatomy may be more commonly encountered at our center than at other centers. As such, the reported technical and clinical success rates at our center may not be generalizable at a population level. Moreover, although the utilization of a rigidizing overtube demonstrated high technical success, the device was used in a limited number of patients. Finally, the number of patients in our sample referred for pancreatic evaluation was low. As a result, it is difficult to draw any conclusions regarding ERCP in post-PD patients for pancreatic indications from our study. Larger studies are required to further assess the utility of rigidizing overtubes in patients with surgically altered anatomy. Additional studies will also be required to evaluate conventional ERCP for pancreatic indications and to assess the generalizability of our results across samples in post-surgical patients.
In conclusion, ERCP is an effective therapeutic biliary procedure in post-PD patients. This study demonstrates the successful use of a rigidizing overtube in facilitating post-PD ERCP. However, post-PD ERCP remains a technically challenging procedure. Altered anatomy may preclude successful navigation of the afferent limb, given the additional length that needs to be traversed along with sharp angulation and looping in the gastrointestinal tract. Moreover, the lack of devices specifically designed for post-surgical anatomy poses an additional challenge. However, additional devices and techniques, including balloon-assisted enteroscopy, EUS-guided techniques, and rigidizing overtubes may be potential solutions to assist in post-PD patients requiring ERCP. In particular, the use of a rigidizing overtube may assist in straightening the angulation, preventing loop formation, and enhancing stability to reach the anastomotic site and facilitate the intervention. However, further studies will need to be conducted to evaluate the use of rigidizing overtubes in post-PD ERCP patients.
The data that support the findings of this study are available from the corresponding author upon reasonable request.
No potential conflict of interest relevant to this article was reported.
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