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ERCP and accessing the

ampulla of vater in the bariatric patient

Douglas A. Howell, MD, FASGE, Gennadiy Bakis, MD

From the Pancreaticobiliary Center, Maine Medical Center, Portland, Maine.

Common bile duct obstruction by gallstones is a frequent occurrence in patients following rapid weight loss after successful Roux-en-Y gastric bypass. The challenge of accessing the papilla and performing successful therapeutic ERCP is undergoing rapid development. This chapter will review recent developments and suggest a treatment algorithm.

© 2010 Elsevier Inc. All rights reserved. KEYWORDS:

ERCP; RNYGB; Enteroscopy

Bariatric surgical procedures have become important tools in addressing the obesity epidemic throughout the world. More than 150,000 bariatric procedures are performed annually in the United States with Roux-en-Y gastric bypass (RNYGB) currently the most popular procedure, accounting for more than two-thirds of surgical volume.1Endoscopists frequently encounter patients needing biliary interventions in the setting of prior gastric bypass surgery. In a prospective study of 81 patients undergoing gastric bypass surgery for morbid obesity, 36% developed gallstones and 13% developed gallbladder sludge after 6 months of follow-up, which coincided with a period of maximum weight loss.2Sphincter of Oddi dysfunc-tion is also described after gastric bypass.3

Accessing the right upper quadrant to perform successful therapeutic ERCP in the postbariatric surgery patient rep-resents a rapidly evolving topic. Earlier obesity operations included the original jejunoileal bypass, and later, the Ma-son vertical banded gastroplasty, but neither of these oper-ations altered the foregut to prevent standard ERCP access. Currently, performed restrictive procedures, such as the adjustable laparoscopically placed proximal gastric band (Lap-Band, Allergan, Inc., Irvine, CA) does not signifi-cantly affect endoscopic access to the papilla.

In the setting of long limb bypasses, the length of bypassed bowel varies depending on the indication for Roux-en-Y limb reconstruction and is greatest in bariatric procedures. Open surgical RNYGB represented a major alteration that frequently made per-oral access impossible with the standard of the day, pediatric colonoscopes, and push enteroscopes. Successful per-oral ERCPs were reported4,5but required long procedural times and experienced frequent failures. Adhesions producing fixa-tion often at sharp turns or long limbs producing excellent weight loss results would generally predict failure to reach the right upper quadrant. Greater success was noted in patients with shorter bypass limbs generally indicated by poor weight loss, and in patients who had had an uncomplicated single abdominal operation. However, successful complex therapeu-tic ERCP could be safely performed on the occasion when the papilla could be reached.5

The development of laparoscopic RNYGB has ushered in a new population of patients needing ERCP. Important differ-ences exist between the older open Roux-en-Y operation and the modern laparoscopically performed one. The laparoscopic Roux-en-Y limb is much longer, resulting in a combined restrictive and malabsorptive mechanism of weight loss. These new 75- to 150-cm bypasses essentially preclude standard per-oral push enteroscopic or per-oral pediatric colonoscopic access. Newer approaches and options to accessing the right upper quadrant have become necessary.

The option of percutaneous transhepatic cholangiogra-phy (PTC) did, and still does, provide for reliable biliary access and drainage as a nonendoscopic alternative. Limi-tations include patient discomfort, complications, especially peritonitis, and bleeding as well as limited therapeutic op-Competing interests. No conflict, royalty, or other agreement exists

between any device mentioned here and any author. Dr. Douglas A. Howell does have royalty agreements for unrelated devices (COOK Endoscopy) and receives lecture fees and research support from Cook, Boston Scien-tific, and Olympus America.

Address reprint requests and correspondence: Douglas A. Howell, MD, FASGE, Portland Gastroenterology, 1200 Congress Street, Portland, ME 04102. E-mail:howeld@mmc.org

Techniques in GASTROINTESTINAL ENDOSCOPY

www.techgiendoscopy.com

1096-2883/10/$-see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.tgie.2010.09.004

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reported by Baron in 1998.6 Since then, ERCP multiple reports documented the performance of ERCP through gas-trostomy either immediately intraoperatively with a sterile duodenoscope or after a period to allow the gastrostomy tract to mature.7An early report suggested a mini-laparot-omy thru the previous open bypass scar could effectively gain access to the bypassed stomach and permit introduction of a sterilized ERCP endoscope.8 Operating times were reasonable and complications of wound infections were few. The details of this procedure include standard laparot-omy preparation, small incision through a portion of the old open surgical scar, and sharp and blunt dissection until the antrum of the stomach was exposed. A purse string was placed around a 12- to 15-mm gastrostomy by the surgeon and the stomach was pulled up to the skin level if possible. After new drapes were placed, the surgeon would take the sterilized endoscope tip and advance it toward the pylorus blindly. The endoscopist would then flex the instrument tip and instruct the surgeon. The papilla would be brought into view often within 15-20 cm of endoscope advancement. The ERCP portion of the procedure was then attempted. This approach had several problems and limitations, includ-ing difficulty advancinclud-ing through the pylorus, need for the surgeon to advance and support the endoscope, exposure by the x-ray beam to the surgeon’s hands, and hampered con-trol of the duodenoscope by the endoscopist. This limitation can prevent orienting the endoscope tip in front of the papilla resulting in failure of the procedure.

In addition, unavoidable leakage of air and fluid around the fresh gastrostomy, at times, prevented adequate duode-nal distension for viewing and may have contributed to the occasional postprocedure wound infection.

Finally, after surgical wound closure, reaccess to the right upper quadrant would be possible only by a full repeat open procedure if an urgent need for repeat ERCP arose, for in-stance, to manage postsphincterotomy bleeding or a missed stone.

Overall this open technique can be done successfully, but when patient postoperative discomfort, length of stay, and complications are tabulated, this approach should now be reserved for failures of other endoscopic options. The ex-ception may be with patients with extensive adhesions due

and avoids the surgeon needing to advance or support the endoscope in the sterile field (Figure 2). The performance of the ERCP then closely resembles standard per-oral ERCP. Some notable differences should be outlined.

Unlike a dedicated ERCP suite, the operating room is not configured optimally for ERCP. A simple C-arm and some-what distant monitor (Figure 3) requires great care to avoid errors in cannulation and sphincterotomy orientation. The endoscopes advancement from an anterior approach, with the patient in the supine position, results in the papilla being further away and often further to the left (Figure 4). Nev-ertheless, successful therapeutic ERCP is the rule and short procedure times can be achieved for simple procedure in-dications. When a repeat ERCP is anticipated, a laparo-scopic creation of a gastrostomy can be preformed to permit

Figure 1 Artist’s drawing of the laparoscopic inserted 15-mm port placement for transgastric ERCP using a standard side-view-ing treatment endoscope. (Color version of figure is available online atwww.techgiendoscopy.com.)

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future interventions.10 Finally, wound infections appear to be less than with open laparotomy, likely due to the better control of leakage (Figures 5 and6).

Although generally successful, accessing with a 15-mm port results in very high costs due to the combined surgical and endoscopic resources needed. From this discussion, it is clear that development of per-oral Roux-en-Y ERCP re-mains the goal.

Per-oral enteroscopic ERCP

in bariatric Roux-en-Y anatomy

Formerly, in patients with Roux-en-Y anatomy, ERCP could be attempted with a duodenoscope, a standard push enteroscope, or a pediatric colonoscope. Challenges include choosing the correct limb at jejunojejunostomy. In patients with short limb postoperative anatomy, success in reaching papilla with a duodenoscope was achieved in only 33%, and

none of these patients were bariatric.11 Elton5 has reported using either enteroscopes (240 cm) or pediatric colonoscopies (168 cm) with overall success rate of 12 of 14 procedures (86%); 4 of the patients had undergone previous open bariatric RNYGB surgery.

In an approach reported by Wright,12cannulation was first attempted after reaching the papilla with a forward viewing instrument and, if not successful, a guidewire or extraction balloon were left in the excluded stomach or duodenum and duodenoscope was advanced over it. The procedure was suc-cessful in 10 of 15 patients (67%), 11 of whom had undergone gastric bypass for morbid obesity previously.

Since the advent of newer devices, enteroscopic/ERCP has been attempted and increasingly reported. Double and more recently single balloon overtube assisted enteroscopes have been used to perform ERCP in patients with bariatric Roux-en-Y anatomy. Most recently, a manually rotatable overtube for enteroscopy insertion (Discovery SB; Spirus

Figure 2 Endoscope insertion through the 15-mm laparoscopic port.

Figure 3 Re-draped patient on the OR table with C-arm in place.

Figure 4 Endoscope position through the 15-mm port viewed by the operating room C-arm.

Figure 5 A 15-mm port with seal. (Color version of figure is available online atwww.techgiendoscopy.com.)

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Medical, West Bridgewater, Masschusetts) has been used for RNYGB and will be discussed.

Performing per-oral ERCP with newer overtube devices using slim 200-cm enteroscopes in bariatric gastric bypass patients presents multiple challenges. Navigating through gas-trojejunostomy, jejunojejunostomy, choosing the afferent limb, and advancing proximally through it to the papilla continues to be difficult. Although adhesions in this era of laparoscopic RNYGB are minimal, distances from the gastric pouch to the papilla may exceed 200 cm in these bariatric patients. Once the papilla is reached, cannulation almost invariably proves to be difficult because of poor visual orientation using the front-viewing available enteroscopes in the setting of intact papillas and limited ERCP accessories of sufficient length. Understand-ing a particular patient’s Roux-en-Y anatomy is essential be-fore attempting this route.

The initial advance in improved endoscopic access to the small bowel for enteroscopy was described by Yamamoto after extensive design and testing of a double balloon system of “push/pull” enteroscopy (DBE/EN450T5; Fuginon, Inc., To-kyo, Japan). The technique involves a balloon-tipped endoscope to hold the advanced enteroscope in position as an overtube is advanced to the tip. A second balloon on the overtube tip is then inflated, the overtube is pulled back to pleat the small bowel onto the overtube, and after deflation of the endoscope balloon, the enteroscope is further advanced (Figure 7).

Shortly after his development of this double-balloon system, Yamamoto reported successful access to the RUQ through RNYGB13followed by the first mention in English of successful Roux-en-Y ERCP using DBE in his textbook in 2005.14

In a small early series reported by Emmett,15 seven consecutive patients with bariatric RNYGB had successful access to the papilla, and all but one had successful thera-peutic interventions. Procedures were long, however, aver-aging 99⫾ 48 minutes.

A larger series appeared to establish DBE as a viable

Our group reported 7 successful therapeutic ERCP procedures among 8 patients with bariatric RNYGB, including 3 sphincterotomies, 2 of which were pancreatic (Figure 8). A new technique of nasopancreatic drainage led out thru the Roux-en-Y limb assisted in avoiding post-ERCP pancreatitis and prevented the need for repeat SBE ERCP.18

Experience at Mayo Clinic among 56 postsurgical Roux-en-Y cases, most cases having been done for weight loss, reported diagnostic cases in 70% and therapeutic success in 21/21 (91%) where indicated. Of note, this larger series had only 5 sphincterotomies, emphasizing the early experience with these efforts.19

A final development has been the introduction of a rotational overtube, which fits the two available 9.2-mm enteroscopes. A soft spiral projection, or fingers, gently pulls the small bowel onto the overtube using manual clock-wise rotation after the device and enteroscope are advanced into the small bowel (Figure 9). This rotational spiral over-tube has now been used to gain access to the right upper quadrant for ERCP (Figures 10and11).

ERCP and enteroscopy success was recently evaluated in a multicenter registry in 129 patients with long limb surgical

Figure 6 Purse string being held around greater curvature gastrostomy and the 15-mm port. (Color version of figure is available online atwww.techgiendoscopy.com.)

Figure 7 Double balloon enteroscopy with front balloon load-ing device (Fuginon, Inc., Tokyo, Japan). (Color version of figure is available online atwww.techgiendoscopy.com.)

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bypass using single or double balloon enteroscopes or ro-tational overtube enteroscopy. Enteroscopy success was similar among single, double, or rotational overtube, rang-ing from 60% to 65% with failures still due primarily to inability to reach the papilla. Patients with failed per-oral ERCP underwent PTC or laparoscopically assisted ERCP at the discretion of each center.20

At this time, when ERCP is performed via the per-oral approach in laparoscopic RNYGB patients, the choice of endoscope and overtube depends on local expertise and availability. A suggested tree to add in choosing the best access approach for differing patient groups is included (Figure 12).

Regardless of choice of endoscope, general anesthesia should be employed because of long procedure times and the complicated nature of access. Additionally, because reintervention may be needed in the future, it may be helpful to mark the afferent limb with ink tattoo to ease subsequent understanding of the anatomy.

Additionally, disadvantages of using enteroscopes for ERCP include small channel size and relatively unstable endoscope handling. Fortunately, some suitable endoscopic accessories are available as colonoscopic length devices generally are long enough to pass through the biopsy chan-nel as opposed to the 240-cm push enteroscope.

Once the papilla is reached, it may be easiest to attempt cannulation with instrument with the straightest tip possible,

Figure 8 Single balloon enteroscopic ERCP through a very long Roux-en-Y limb. Note successful entry into a dilated pancre-atic duct.

Figure 9 Rotational overtubes (Spirus Medical, West Bridge-water, Masschusetts). (Color version of figure is available online at www.techgiendoscopy.com.)

Figure 10 Rotational overtube enteroscopic ERCP. Note the spiral “fingers” on the image on the left and the successful stent guided sphincterotomy being performed onFigure 11.

Figure 11 Successful ERCP sphincterotomy using stent guided needle knife technique.

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preloaded with a long hydrophilic guidewire. A side port can be attached to any device to permit coaxial injection of contrast.

Standard papillatomes usually orient themselves with cutting wire facing away from the desired direction of the sphincterotomy and therefore cannot be used for sphincter-otomy. A common approach is to place a temporary stent after a guidewire is inserted and perform a needle knife sphincterotomy over it. Over the guidewire exchange of devices is challenging due to long lengths of catheters and require injecting saline at high pressure to “shoot” the wire forward. It is sometimes possible to “groom” a standard sphincterotome in such a way that the cutting wire is facing towards 5-o’clock position for biliary sphincterotomy. A suitable sphincterotome has yet to be developed, however.

Conclusions

The need for therapeutic ERCP in the setting of bariatric RNYGB is growing rapidly as an ever-increasing number of operations are performed on a population of predominately young people.

Rapid weight loss is associated with a high rate of gall stone formation with a corresponding high rate of passage into the common bile duct.

As reviewed in this chapter, multiple options to access the papilla have recently been developed. An algorithm is suggested for centers having the full range of equipment and experience. Industry is aware of the challenge of per-oral Roux-en-Y endoscopy and hopefully will respond to pro-duce endoscopes and accessories specifically designed to improve success and shorten procedures. Newer overtubes have demonstrated the potential of accessing the papilla in most bariatric Roux-en-Y cases. Success approaching the near universal success of standard anatomy ERCP will await this development challenge.

References

1. Proceedings of the ASBS Consensus Conference on the State of Bariatric Surgery and Morbid Obesity: Health Implications for Pa-tients, Health Professionals and Third-Party Payers, Washington, DC, USA, May 6-7, 2004. Surg Obes Relat Dis 1:105-153, 2005

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2. Shiffman ML, Sugerman HJ, Kellum JM, Brewer WH, Moore EW: Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am J Gastroenterol 86:1000-1005, 1991

3. Morgan KA, Glenn JB, Byrne TK, Adams DB: Sphincter of Oddi dysfunction after roux-en-Y gastric bypass. Surg Obes Relat Dis 5:571-575, 2009

4. Gostout CJ, Bender CE: Cholangiopancreatography, sphincterotomy, and common duct stone removal via roux-en-Y limb enteroscopy. Gastroenterology 95:156-163, 1988

5. Elton E, Hanson BL, Qaseem T, Howell DA: Diagnostic and thera-peutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients. Gastrointest Endosc 47:62-67, 1998

6. Baron TH, Vickers SM: Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Gastrointest Endosc 48:640-641, 1998

7. Matlock J, Ikramuddin S, Lederer H, Cass O: Bypassing the bypass: ERCP via gastrostomy after bariatric surgery. Gastrointest Endosc 61:AB98, 2005

8. Bernadino KP, Lawrence C, Ansari A, et al: Successful ERCP in the gastric bypass patient: employing surgical access to the excluded stomach. Gastrointest Endosc 61:AB199, 2005

9. Peters M, Papasavas PK, Caushaj PF, Kania RJ, Gagne DJ: Laparo-scopic transgastric endoLaparo-scopic retrograde cholangiopancreatography for benign common bile duct stricture after roux-en-Y gastric bypass. Surg Endosc 16:1106, 2002

10. Pimentel RR, Mehran A, Szomstein S, Rosenthal R: Laparoscopy-assisted transgastrostomy ERCP after bariatric surgery: case report of a novel approach. Gastrointest Endosc 59:325-328, 2004

11. Hintze RE, Adler A, Veltzke W, Abou-Rebyeh H: Endoscopic access to the papilla of Vater for endoscopic retrograde

cholangiopancreatog-raphy in patients with Billroth II or roux-en-Y gastrojejunostomy. Endoscopy 29:69-73, 1997

12. Wright BE, Cass OW, Freeman ML: ERCP in patients with long-limb roux-en-Y gastrojejunostomy and intact papilla. Gastrointest Endosc 56:225-232, 2002

13. Sakai P, Kuga R, Safatle-Ribeiro AV, et al: Is it feasible to reach the bypassed stomach after roux-en-Y gastric bypass for morbid obesity? The use of the double-balloon enteroscope. Endoscopy 37:566-569, 2005

14. Yamamoto H: Double-Balloon Endoscopy. Tochigi, Japan, Springer, 2005

15. Emmett DS, Mallat DB: Double-balloon ERCP in patients who have undergone roux-en-Y surgery: a case series. Gastrointest Endosc 66: 1038-1041, 2007

16. Simon KL, Gauree G, Richard AK, et al: Double balloon enteroscopy (DBE) Can Be routinely employed to perform ERCP in bariatric gastric bypass (RYGB) patients. Gastrointest Endosc 67:AB235, 2008 17. Neumann H, Fry LC, Meyer F, Malfertheiner P, Monkemuller K: Endoscopic retrograde cholangiopancreatography using the single bal-loon enteroscope technique in patients with roux-en-Y anastomosis. Digestion 80:52-57, 2009

18. Howell DA, Srinivasan R, Stefan AS: Diagnostic and therapeutic ERCP in Long-limb surgical bypass patients using a new single-balloon assisted enteroscope. Gastrointest Endosc 69:AB271-AB272, 2009

19. Saleem A, Baron TH, Gostout CJ, et al: Endoscopic retrograde cholan-giopancreatography using a single-balloon enteroscope in patients with altered roux-en-Y anatomy. Endoscopy 42:656-660, 2010 20. Shah RJ, Smolkin M, Ross A, et al: A multi-center, U.S. experience of

single balloon, double balloon, and rotational overtube enteroscopy-assisted ERCP in Long limb surgical bypass patients. Gastrointest Endosc 71:AB134-AB135, 2010

References

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