ERCP in patients with surgically altered anatomy: retrospective single tertiary referral center study

 

Aims ERCP is considered the first-line treatment for several biliary and pancreatic diseases and is technically demanding in patients with surgically altered anatomy (SAA) like gastrectomy or Rou-ex-Y reconstruction. Afferent loop (AL) intubation, selective biliary or pancreatic cannulation and sphincterotomy are the main issues especially for the absence of available and dedicated devices.

Methods From August 2013 to October 2023, we retrospective enrolled 30 patients with SAA who underwent ERCP: 22 men (73%) and 8 female (27%) [mean age of 74±9 years]. Surgical reconstruction was Billroth II (21 cases\70%), roux-en-Y gastric bypass (1 case\3%), pancreaticoduodenectomy (4 cases\13%) and total gastrectomy (4 cases\13%). Native papilla and biliopancreatoenteric anastomosis were reported in 26 and 4 patients, respectively. The main indications were common bile duct stones (50%), neoplastic obstructive jaundice (33%), bilio-pancreatic leak (7%) and bilio-digestive anastomotic stricture (10%). Procedures were performed using a duodenoscope (62%), colonoscope (12%), gastroscope (12%), linear echoendoscope (3%), single (3%)\double (7%) balloon enteroscope.

Results Mean operative time was 56±32 minutes. The successful duodenal intubation rate was 80% (24/30) and the impossibility to reach the target biliary area was 20%, in 3 cases for a too long Roux-en-Y limb and in 3 cases for angulated AL complied by a iatrogenic perforation using the duodenoscope (tip or side). Successful cannulation of desired biliopancreatic duct was 100% (24/24). In particular, 2 of 24 patients presented a bilio-digestive anastomotic stricture that was treated with hydro-pneumatic balloon dilatation and multistenting technique with plastic stents. In the other 22 cases, biliary sphincterotomy were successfully performed in 95% patients (21/22) with a unique technical failure (5%) even rotating the sphincterotome or using the straight cannula. Major papilla hydropneumatics dilatation, stone-extraction and biliary stenting were technically executed in all the cases. We reported also a single case of gastric bypass reconstruction with access of the excluded stomach by creating a gastro-gastro anastomosis with lumen-apposing metal stent (LAMS), and a subsequent EUS-directed transgastric ERCP (EDGE) using a duodenoscope passing though the LAMS to reach the papillary area and performing biliary sphincterotomy.

Conclusions In patients with SAA, understand the different types of postoperative reconstruction is fundamental to determine the easiest way to access the AL and reach the target (native papilla or bilio-pancreatoenteric anastomosis). Choose the most appropriate endoscopic instrument, accessories and technique will allow to increase technical success and prevent operative complications [1]. After reaching the biliary target, that remain the main technical issue in SAA, the endoscopic technique present similar rate of efficacy compared to patients with normal anatomy but requiring more procedural time and higher technical skills.

Publication History

Article published online:
15 April 2024

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• References

• 1 Gkolfakis P., Papaefthymiou A., Facciorusso A.. et al. “Comparison between enteroscopy-, laparoscopy- and endoscopic ultrasound-assisted endoscopic retrograde cholangio-pancreatography in patients with surgically altered anatomy: a systematic review and meta-analysis,”. Gastroenterology Research and Practice 2023; 6678991
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