title: A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video).
abstract: BACKGROUND
  Data on overtube-assisted enteroscopy to facilitate ERCP in patients with surgically altered pancreaticobiliary anatomy, or long-limb surgical bypass, is limited.
  
  
  OBJECTIVE
  To evaluate and compare ERCP success by using single-balloon (SBE), double-balloon (DBE), or rotational overtube enteroscopy.
  
  
  METHODS
  Consecutive patients identified retrospectively.
  
  
  METHODS
  Eight U.S. referral centers.
  
  
  METHODS
  Long-limb surgical bypass patients with suspected pancreaticobiliary diseases.
  
  
  METHODS
  Overtube-assisted enteroscopy ERCP.
  
  
  METHODS
  Enteroscopy success: visualizing the pancreaticobiliary-enteric anastomosis or papilla. ERCP success: completing the intended pancreaticobiliary intervention. Clinical success: greater than 50% reduction in abdominal pain or level of hepatic enzyme elevations or resolution of jaundice.
  
  
  RESULTS
  From January 2008 through October 2009, 129 patients had 180 enteroscopy-ERCPs. Anatomy was Roux-en-Y: gastric bypass (n = 63), hepaticojejunostomy (n = 45), postgastrectomy (n = 6), Whipple procedure (n = 10), and other (n = 5). ERCP success was 81 of 129 (63%). Enteroscopy success: 92 of 129 (71%), of whom 81 of 92 (88%) achieved ERCP success. Reasons for ERCP failure (n = 48): afferent limb entered but pancreaticobiliary anastomosis and/or papilla not reached (n = 23), cannulation failure (n = 11), afferent limb angulation (n = 8), and jejunojejunostomy not identified (n = 6). Select interventions: anastomotic stricturoplasty (cautery ± dilation, n = 16), stone removal (n = 21), stent (n = 25), and direct cholangioscopy (n = 11). ERCP success rates were similar between Roux-en-Y gastric bypass and other long-limb surgical bypass and among SBE, DBE, and rotational overtube enteroscopy. Complications were 16 of 129, 12.4%.
  
  
  CONCLUSIONS
  Retrospective study.
  
  
  CONCLUSIONS
  (1) ERCP is successful in nearly two-thirds of long-limb surgical bypass patients and in 88% when the papilla or pancreaticobiliary-enteric anastomosis is reached. (2) Enteroscopy success in long-limb surgical bypass is similar among SBE, DBE, and rotational overtube enteroscopy methods. (3) Referral of long-limb surgical bypass patients who require ERCP to high-volume institutions may be considered before more invasive percutaneous or surgical alternatives.
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA. raj.shah@ucdenver.edu
authors.forename: Raj J
authors.initials: RJ
authors.lastname: Shah
authors.forename: Maximiliano
authors.initials: M
authors.lastname: Smolkin
authors.forename: Roy
authors.initials: R
authors.lastname: Yen
authors.forename: Andrew
authors.initials: A
authors.lastname: Ross
authors.forename: Richard A
authors.initials: RA
authors.lastname: Kozarek
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Howell
authors.forename: Gennadiy
authors.initials: G
authors.lastname: Bakis
authors.forename: Sreenivasan S
authors.initials: SS
authors.lastname: Jonnalagadda
authors.forename: Abed A
authors.initials: AA
authors.lastname: Al-Lehibi
authors.forename: Al
authors.initials: A
authors.lastname: Hardy
authors.forename: Douglas R
authors.initials: DR
authors.lastname: Morgan
authors.forename: Amrita
authors.initials: A
authors.lastname: Sethi
authors.forename: Peter D
authors.initials: PD
authors.lastname: Stevens
authors.forename: Paul A
authors.initials: PA
authors.lastname: Akerman
authors.forename: Shyam J
authors.initials: SJ
authors.lastname: Thakkar
authors.forename: Brian C
authors.initials: BC
authors.lastname: Brauer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001652:Bile Ducts / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000295:instrumentation* / Q000379:methods*; D058582:Double-Balloon Enteroscopy / Q000295:instrumentation; D020776:Endoscopes, Gastrointestinal; D016099:Endoscopy, Gastrointestinal; D004867:Equipment Design; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000601:surgery*; D012189:Retrospective Studies; D014481:United States; D055815:Young Adult