The study took place from January 2009 to December 2011 and we retrospectively assessed 15 patients (7 men, average age: 55 years; 8 women, average age: 53 years) with Roux-en-Y HJA, who had signs of biliary obstruction.

Altogether 23 ERC procedures were performed in these 15 patients with Roux-en-Y HJA using a single balloon videoenteroscope (Olympus SIF Q 180). Its working length was 200 cm, the outer diameter was 9.2 mm, and the diameter of the working channel was 2.8 mm. A transparent overtube was drawn over a single balloon enteroscope and it freely moved on the working part of the enteroscope. The overtube was 13.2 mm in diameter and 140 cm long. The distal end was equipped with a silicon balloon that was filled with air from an external pump up to a maximum pressure of 5.4 kPa. Inflation and deflation of this silicon balloon were performed by means of the external pump control.

The examination was performed after a 12-h fast. This endoscopic procedure was both time consuming and technically demanding and required the presence of an anesthesiologist. The mean time to perform the procedure was 72 min. The longest procedure took 110 min and the shortest took 34 min.

During the procedure, the patient lay on the left side and received intravenous sedation (mainly in various combinations) with: midazolam 1-5 mg, sufentanil 5-10 µg, and propofol 20-40 mg repeatedly, to a maximum dose of 200 mg. Buscopan was used after reaching the blind end of the afferent intestinal loop when looking for the HJA orifice.

As can be seen in the schematic image with Roux-en-Y HJA (Figure 1), if an endoscopist wishes to reach the target location, that is, the orifice of the HJA, he/she needs to cover a long distance using a single balloon enteroscope - namely the esophagus, stomach, duodenum, duodenojejunal flexure, proximal jejunum, enteroenteroanastomosis, and afferent intestinal loop, where, at its distal end, 5-6 cm before the blind end of the intestinal loop, lies the orifice of the HJA. Non-ionic iodinated contrast medium (Omnipaque 300) was used for X-ray imaging of the biliary system.

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Figure 1 Schematic image of Roux-en-Y hepaticojejunoanastomosis[22].

As already mentioned above, the technical limitations or parameters of the single balloon enteroscope (working length - 200 cm, diameter of the working channel - 2.8 mm, absence of Albarran bridge) necessitate the use of special endoscopic instrumentation.

First, a cannula (width 6 Fr and length 330 cm, or width 7 Fr and length 312 cm; Cook Co., Bloomington, IN, United States) was used for cannulation of the orifice of the HJA and the adjoining bile ducts. Later, a triple-lumen extraction balloon was used more frequently for cannulation of the orifice of the HJA, which enabled simultaneous application of the contrast medium and insertion of the guidewire, which made cannulation significantly more effective. This triple-lumen extraction balloon is described below, and it is used, in addition to cannulation of the orifice of the HJA, for endoscopic extraction of choledocholithiasis.

An especially long guidewire of 600 cm (width 0.035 inches; Cook) was used specifically for this type of procedure using a single balloon enteroscope. HJA stenosis was endoscopically dilated by a bougie dilator (7 Fr) and by a balloon dilator (Cook Co., dilatation balloon type QBD, diameter 10 mm, balloon length 3 cm, designated for 2.8 mm diameter working channel, total length of instrument 320 cm). This balloon dilator was used for dilation under a pressure of 3 atm for 2 min.

Choledocholithiasis was endoscopically extracted using the above mentioned triple-lumen extraction balloon (Cook, TXR- HE, width 6.6 Fr, length 275 cm). Plastic biliary drains - width 7 Fr (and in 1 patient also 8.5 Fr), length 3-5 cm (Medinet or Cook or MSA) - were inserted endoscopically. Apart from others, Cook pusher, width 7 Fr, length 320 cm, was used. In cases of biliary obstruction, these inserted biliary drains were endoscopically removed using a polypectomy loop (Olympus).

The study was performed in accordance with the ethical criteria of the Declaration of Helsinki. The study was reviewed and approved by the Ethics Committee of St. Anne’s University Hospital Brno. Written informed consent to perform diagnostic and therapeutic ERC using a single balloon enteroscope was obtained from all the patients.

ERC was performed three times in patient 1 (49-year-old woman). A narrow HJA stenosis was found during the first ERC procedure. Endoscopic balloon dilation of this HJA stenosis was subsequently performed, followed by endoscopic insertion of an 8.5 Fr plastic biliary drain into the bile duct, which completely bridged the HJA stenosis. Another ERC procedure was performed under the same conditions 1 mo later. No complications occurred during this month. Initially, an 8.5 Fr biliary drain was endoscopically extracted. After that, a control ERC was performed, showing that the original HJA stenosis was less prominent. Subsequently, repeat endoscopic balloon dilation of the HJA stenosis was performed. At the end of the second ERC session, an 8.5 Fr plastic biliary drain was repeatedly inserted into the bile duct. A third ERC was performed under the same conditions 1 mo later. An 8.5 Fr biliary drain was endoscopically extracted and a control ERC was performed, which showed a smaller HJA stenosis compared with the previous ERC. Another endoscopic balloon dilation of the small HJA stenosis was performed followed by control ERC. The results were satisfactory, showing almost no HJA stenosis. The procedure was then finished. Both the diagnostic and therapeutic ERC in this patient were therefore successful. The patient had no complications after the first ERC.

ERC was performed once in patient 2 (64-year-old woman) and there was only a slight manifestation of HJA stenosis. Endoscopic balloon dilation of this HJA stenosis was subsequently performed followed by control ERC, with satisfactory results and absence of HJA stenosis. Both the diagnostic and therapeutic ERC were therefore successful.

Successful diagnostic ERC was performed once in patient 3 (26-year-old woman) and showed cystic dilation of the bile duct. The condition was primarily resolved surgically, that is, without any attempt to perform endoscopic therapy.

The orifice of the HJA was found in patient 4 (60-year-old man). However, the attempt to probe the orifice was not successful, therefore, ERC was not performed. This was a case of cannulation failure, thus, the condition had to be resolved by PTC and percutaneous transhepatic drainage (PTD).

ERC was performed once in patient 5 (67-year-old man) and it showed slight choledocholithiasis. Endoscopic extraction of the choledocholithiasis using a balloon followed. Both the diagnostic and therapeutic ERC were therefore successful.

ERC was performed twice in patient 6 (57-year-old woman) and slight HJA stenosis and choledocholithiasis were found. Endoscopic balloon dilation of the HJA stenosis was performed during the first ERC, followed by endoscopic balloon extraction of the choledocholithiasis. Control ERC showed satisfactory results for the biliary tree. Both the diagnostic and therapeutic ERC were therefore successful.

ERC was performed twice in patient 7 (52-year-old man). The first ERC showed slight HJA stenosis and choledocholithiasis. Balloon dilation of the HJA stenosis was performed first, followed by endoscopic extraction of the choledocholithiasis using an extraction balloon. Control ERC showed satisfactory results in the biliary tree. Both the diagnostic and therapeutic ERC were therefore successful.

Patient 8 (29-year-old man) underwent HJA construction for a condition that developed after OLT for PSC. ERC was performed three times. The first ERC showed a narrow HJA stenosis. Endoscopic balloon dilation of the stenosis was subsequently performed, followed by endoscopic insertion of a 7 Fr plastic biliary drain into the bile duct, which completely bridged the HJA stenosis. The second ERC was performed under the same conditions 1 mo later. No complications occurred during that month. First, a 7 Fr biliary drain was endoscopically extracted. After that, control ERC was performed, showing that the original HJA stenosis was less prominent. Repeated endoscopic balloon dilation of the HJA stenosis was performed. At the end of the second ERC session, a 7 Fr plastic biliary drain was inserted into the bile duct. Third, control ERC was performed under the same conditions 6 wk later. A 7 Fr biliary drain was endoscopically extracted and control ERC was performed, showing significant improvement of the HJA stenosis, which was in fact unnoticeable. Both the diagnostic and therapeutic ERC in this patient were therefore successful.

Successful diagnostic ERC was performed once in patient 9 (64-year-old man) and showed normal findings.

ERC was performed twice in patient 10 (48-year-old woman). The first ERC showed HJA stenosis and slight choledocholithiasis. Balloon dilation of the HJA stenosis was performed first, followed by endoscopic extraction of the choledocholithiasis using an extraction balloon. A 7 Fr plastic biliary drain was subsequently inserted into the bile duct, completely bridging the HJA stenosis. Control ERC in 4 wk (i.e., during the second ERC session) showed satisfactory findings in the bile duct. Both the diagnostic and therapeutic ERC were therefore successful.

ERC was performed once in patient 11 (56-year-old woman) and prominent HJA stenosis was found. Therapeutic ERC, that is, insertion of a balloon or biliary drain into the HJA stenosis, was not possible because the stenosis was too narrow. This led to PTC and PTD. Successful diagnostic ERC was therefore performed once in this patient.

ERC was performed once in patient 12 (59-year-old woman) and slight choledocholithiasis was found. Endoscopic extraction of the choledocholithiasis using an extraction balloon was subsequently performed. Both the diagnostic and therapeutic ERC were therefore successful.

The area of the distal end of the afferent intestinal loop was reached by single balloon enteroscopy in patient 13 (63-year-old woman), nevertheless the HJA was not found. ERC was therefore not performed. This was a case of cannulation failure, thus, the condition had to be resolved by PTC and PTD.

The orifice of the HJA was found in patient 14 (59-year-old woman), nevertheless, the attempt to probe the orifice was not successful. ERC was therefore not performed. This was a case of cannulation failure, thus, the condition had to be resolved by PTC and PTD.

ERC was performed once in patient 15 (54-year-old man). The first ERC showed HJA stenosis. Endoscopic balloon dilation of the stenosis was performed, followed by endoscopic insertion of a 7 Fr plastic biliary drain into the bile duct, which completely bridged the HJA stenosis. The second ERC was performed under the same conditions 1 mo later. No complications occurred during that month. First, a 7 Fr biliary drain was endoscopically extracted. After that, control ERC was performed, showing marked improvement, with the original HJA stenosis being almost unnoticeable. In spite of that, endoscopic balloon dilation of the area of the HJA stenosis was performed. At the end of the second ERC session, control ERC was performed, showing almost normal findings, which means that the original HJA stenosis was no longer noticeable. Both the diagnostic and therapeutic ERC in this patient were therefore successful.

The results clearly show that cannulation was successful in diagnostic ERC in 12 of 15 patients (80% diagnostic success rate). The diagnostic ERC findings in these patients are shown in Table 2. Normal ERC findings were present in one of the 12 patients. ERC in the remaining 11 patients showed some pathological findings. One of these cases (cystic dilation of the bile duct) was subsequently resolved by surgery.

Endoscopic treatment was started immediately after diagnostic ERC in the remaining 10 patients (5 with HJA stenosis, 2 with choledocholithiasis, and 3 with both conditions). This treatment was successful in nine patients (90% therapeutic success rate). Therapeutic ERC was not successful in the other patient due to an extremely narrow HJA stenosis. This condition was resolved by PTC and PTD.

Endoscopic therapeutic procedures were performed as follows. Balloon dilatation of HJA stenosis was performed a total of 11 times in seven patients; choledocholithiasis extraction was performed a total of five times in five patients; plastic biliary stent insertion was performed a total of six times in four patients; and removal of a biliary stent inserted by our team was performed a total of six times in four patients.

Some of these endoscopic procedures are presented in Figures 2 and 3.

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Figure 2 Endoscopic image. A: Successful cannulation of a stenotic orifice of the hepaticojejunoanastomosis (HJA) (followed by successful cannulation of adjoining bile ducts); B: Dilation balloon in a deflated form successfully inserted down the guide wire into the area of the stenotic HJA; C: Last phase of a successful endoscopic insertion of a 7 Fr plastic biliary drain into the stenotic HJA and adjoining bile ducts; D: Highly satisfactory final effect of endoscopic treatment of the stenotic HJA (with inserted guide wire).

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Figure 3 Endoscopic retrograde cholangiography performed by using single balloon enteroscopy. A: A patient with hepaticojejunoanastomosis (HJA) shows comparatively narrow HJA stenosis with suprastenotic dilation of bile ducts; B: The patient from Figure 3A in whom HJA stenosis was successfully bridged by endoscopic insertion of a 7 Fr plastic biliary stent.

Cannulation failure was recorded in three of 15 patients. Causes of failure were: one patient in whom HJA was not found at all; and two cases in which HJA was found but not probed. All three cases were resolved using PTC and PTD.

There were no complications in our group of 15 patients.

It is also important to draw attention to some of the pitfalls that we encountered and resolved when performing ERC. (1) Fixing an overtube closely in front of the anastomosis in the area of an enteroenteroanastomosis is not recommended because the overtube, in case of the entrance to the afferent intestinal tube being at an acute angle, made insertion of the enteroscope harder; (2) The afferent intestinal loop could be identified by finding its blind end, and bilioenteral anastomosis can be found a few (5-6) centimeters before this blind end; (3) We suggest using endoscopic accessorium of diameter no larger than 7 Fr in the working channel of the single balloon enteroscope (2.8 cm diameter). Based on our personal experience, the use of an 8.5 Fr dilator and biliary drain, or their insertion via the working channel, was difficult. A 7 Fr dilator was much easier to use for dilation and was followed by the use of a dilation balloon. Biliary drainage was, in indicated cases, easier to perform using two 7 Fr drains; and (4) It is advised to straighten the overtube during extraction of the enteroscope from the overtube by manipulation under skiascopic control but, at the same time, it is necessary to prevent the creation of curves that are small in diameter because they tend to break after the removal of the enteroscope, and make repeated insertion complicated.

Single balloon enteroscopy (SBE) was originally and still is used for endoscopic diagnosis and treatment of diseases of the small intestine. It was also introduced in endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepaticojejunoanastomosis (HJA), especially in cases in which standard ERC (by lateroscopy) was unsuccessful, because it was impossible to reach the area of the HJA.

The need to continue developing and possibly improving equipment (both endoscopes and endoscopic accessories) is still present. They should be better adjusted to the needs of the ERC procedures in patients with Roux-en-Y HJA (enteroscopes with sideways or oblique optics with an elevator, shorter enteroscopes with wider channels specially designed for these procedures, and development of endoscopic accessories of greater length).

When surgically altered gastrointestinal or pancreatobiliary anatomy is present, endoscopic retrograde cholangiopancreatography becomes even more demanding than in a normal anatomical situation. In spite of that, we managed to achieve a comparatively high success in diagnostic (80%) and therapeutic (90%) ERC using single balloon enteroscopy in our cohort of 15 patients with Roux-en-Y HJA, and there were no complications after ERC.

ERC using single balloon enteroscopy in patients with Roux-en-Y HJA is time consuming and technically demanding. Nevertheless, it is also an effective and safe method that widens the possibilities of resolving biliary tract diseases. Previously, the only possibility of resolution was using percutaneous transhepatic cholangiography or a surgical approach.

The study reported high-quality results of diagnostic and therapeutic ERC using single balloon enteroscopy in patients with Roux-en-Y HJA. The study retrospectively evaluated 15 patients with Roux-en-Y HJA with signs of biliary obstruction. Altogether, 23 ERC procedures were performed without any complications.