Endoscopic approaches to biliary intervention in patients with surgically altered gastroduodenal anatomy

Abstract

Over the past decade the ability of endoscopists to access the biliary tree in patients with surgically altered gastroduodenal anatomy has significantly advanced. Much of the progress has occurred as a result of the development of better tools to navigate the deep small bowel, such as single-balloon- (SBE), double-balloon- (DBE), and spiral-enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP). However, despite using a cap, accessing the papilla or bile duct using these forward-viewing enteroscopy platforms remains challenging, even in expert hands. In patients with Roux-en-Y gastric bypass (RYGB) anatomy, the excluded stomach is a potential point of access for either a delayed transgastric- or immediate laparoscopy-assisted-ERCP approach. However, the parallel advancement of therapeutic endoscopic ultrasound (EUS) also provides alternative approaches through which the biliary system can be accessed and intervened on in patients with surgically altered anatomies. Generally speaking, in patients with short gastro-jejunal “Roux” and bilio-pancreatic limbs, ideally less than 150 cm in length, starting with a (cap-assisted) push-enteroscopy or balloon-enteroscopy approach would offer reasonable diagnostic and therapeutic ERCP success. When available, short-SBE or short-DBE scopes should be used, as they allow the use of conventional ERCP equipment, are associated with shorter procedure times, and are easier to manipulate. In patients with RYGB who have longer Roux and/or bilio-pancreatic limbs (> 150 cm in total length), or in patients who have failed prior attempts at deep enteroscopy-assisted ERCP, transgastric laparoscopy-assisted-ERCP is associated with higher rates of diagnostic and therapeutic success as compared to deep-enteroscopy-assisted ERCP. Finally, EUS-guided biliary access for antegrade biliary intervention or for rendezvous enteroscopy-assisted ERCP is possible. While percutaneous transhepatic biliary drainage and surgical bile duct exploration remain viable alternatives, these methods are not without significant morbidity and mortality and should only be considered if less invasive endoscopic interventions are not feasible or appropriate.

Keywords: Endoscopic retrograde cholangiopancreatography, Bile duct, Roux-en-Y, Gastric bypass, Surgically altered anatomy

Core tip: In patients with short gastrojejunal “Roux” and bilio-pancreatic limbs, ideally less than 150 cm in length, starting with a (cap-assisted) push-enteroscopy or balloon-enteroscopy approach should offer reasonable diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) success. When available, short-single-balloon or short-double-balloon enteroscopes should be used, as they allow the use of conventional ERCP equipment, are associated with shorter procedure times, and are easier to manipulate. In patients with Roux-en-Y gastric bypass who have longer Roux and/or bilio-pancreatic limbs, or in patients who have failed prior attempts at deep enteroscopy-assisted ERCP, transgastric laparoscopy-assisted-ERCP should be considered, which is associated with high rates of diagnostic and therapeutic ERCP success.