Kentaro Ishii, MD, from the Department of Gastroenterology and Hepatology, Tokyo Medical University, in Tokyo, Japan discusses this Original Article, “Balloon enteroscopy–assisted ERCP in patients with Roux-en-Y gastrectomy and intact papillae (with videos).”

Balloon enteroscopy (BE)-assisted ERCP has provided a marked improvement in the success rate of reaching the papilla and consecutive ERCP procedures in patients with surgically altered anatomy in the Roux-en-Y (RY) reconstruction setting. However, limited data are available on the outcome of balloon enteroscopy-assisted ERCP in RY patients with naïve papilla. We retrospectively evaluated the feasibility of balloon enteroscopy-assisted ERCP in RY reconstruction after total or subtotal gastrectomy (RYG) with native papilla.

We performed 123 ERCP procedures in 109 patients with RYG. Among these patients, 90 consecutive ERCPs in 90 patients with native papilla were included. When selective biliary cannulation failed, the double-guidewire technique (DGT), precut, or the rendezvous technique was performed as advanced cannulation methods. The overall success rate of reaching the papilla was 93.5% (115/123). The total procedure success rate was 88.1% (96/109). The adverse event rate was 7.3% (8/109). The success rate of the standard cannulation of the intact papilla was 67.8% (61/90). The final cannulation success rate was 95.6% (86/90) using advanced cannulation methods. Although standard cannulation of the intact papilla in RYG cases remains challenging and uncertain, the use of various advanced cannulation methods improves the deep cannulation rate. Once selective cannulation succeeds, the treatment success rate is very high.

Figure 2. A summary of the ERCP results. EJ, esophagojejunostomy; GJ, gastrojejunostomy; R-Y, Roux-en-Y reconstruction; PTBD, percutaneous transhepatic biliary drainage; EUS-HGS, EUS-guided hepaticogastrostomy; PTC, percutaneous transhepatic cholangiography; EUS-PD, EUS-guided pancreatic drainage.

The difficulty in obtaining a favorable view of the papilla is the main reason for difficult cannulation. Other reasons include limited availability of accessories and diameter of working channel. Particularly when a long-type BE is used, the limitation of accessories is a major problem. However, with the use of prototype long devices, the success rate of standard cannulation using a long-type BE was 67.9% (38/56). When endoscope exchange and/or advanced cannulation methods were added, the final success rate of cannulation was 94.6% (53/56), and the success rate of subsequent ERCP-related treatment was 100% (53/53).

These results suggest that, when there are available catheters and other devices, BE-assisted ERCP is sufficiently feasible even with a long-type BE. Further progress is expected in the field of balloon enteroscopy-assisted ERCP, along with the future technical innovation and development of available scope and accessories. The limitations of this study were its retrospective nature, lack of a control group, and the inclusion of a single-center experience.

Find the abstract for this article here.

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