title: ERCP using a short double-balloon enteroscope in patients with prior pancreatoduodenectomy: higher maneuverability supplied by the efferent-limb route.
abstract: BACKGROUND
  In endoscopic retrograde cholangiopancreatography (ERCP) for patients who have undergone a pancreatoduodenectomy (PD) with a Braun anastomosis, two different approaches are available: the afferent-limb route and the efferent-limb route. This study was to clarify the usefulness of a short double-balloon enteroscope (DBE) in ERCP for prior-PD patients, and to reveal which route was optimal for ERCP.
  
  
  METHODS
  Seventy-two consecutive patients with a prior PD underwent diagnostic or therapeutic ERCP using the DBE. This retrospective study evaluated the outcome of the ERCP and assessed the shape of the DBE by fluoroscopic imaging to compare the maneuverability of the two routes.
  
  
  RESULTS
  In 71 patients (99%) the bilioenteric anastomosis was reached and cholangiography was performed. Treatment was required in 59 patients (83%) and was performed successfully in all. Complications occurred in two patients (3%) with cholangitis. In three patients, the afferent-limb route had to be changed to the efferent-limb route in the procedure. A gentler arc-shaped angulation of the DBE was induced using the efferent-limb route compared to the afferent-limb route (128° (n = 42) vs. 113° (n = 15); p = 0.037), and that was also revealed in 11 patients (15%) who underwent repeated ERCP by each route (123° vs. 96°; p = 0.003).
  
  
  CONCLUSIONS
  The short DBE facilitates ERCP in prior-PD patients. Particularly, ERCP using the efferent-limb route can achieve a maneuverable procedure without unnecessary stress, such as scope insertion to the sharp-angled afferent limb and the handling of various accessories through the narrow scope channel with a sense of resistance.
authors.affiliation: Department of Gastroenterology and Hepatology, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan, ttmkuicru@yahoo.co.jp.
authors.forename: Koichiro
authors.initials: K
authors.lastname: Tsutsumi
authors.forename: Hironari
authors.initials: H
authors.lastname: Kato
authors.forename: Shinichiro
authors.initials: S
authors.lastname: Muro
authors.forename: Naoki
authors.initials: N
authors.lastname: Yamamoto
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Noma
authors.forename: Shigeru
authors.initials: S
authors.lastname: Horiguchi
authors.forename: Ryo
authors.initials: R
authors.lastname: Harada
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Okada
authors.forename: Kazuhide
authors.initials: K
authors.lastname: Yamamoto
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000295:instrumentation*; D002761:Cholangitis / Q000601:surgery*; D058582:Double-Balloon Enteroscopy / Q000295:instrumentation*; D004867:Equipment Design; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy / Q000379:methods*; D012189:Retrospective Studies