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Endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy

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Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass (RYGB), can be more challenging compared to those with a normal anatomy. Detailed assessment of cross-sectional imaging features by the radiologist, especially the pancreaticobiliary anatomy, strictures, and stones, is very helpful to the endoscopist in planning the procedure. In addition, any information on enteral anastomoses (for e.g., gastrojejunal strictures and afferent limb obstruction) is also very useful. The endoscopist should review the operative note to understand the exact anatomy prior to procedure. RYGB, which is performed for medically complicated obesity, is the most commonly encountered altered anatomy ERCP procedure. Other situations include patients who have had a pancreaticoduodenectomy or a hepaticojejunostomy. Balloon-assisted deep enteroscopy (single and double-balloon enteroscopy) or rotational endoscopy is often used to traverse the length of the intestine to reach the papilla. In addition, ERCP in these patients is further challenging due to the oblique orientation of the papilla relative to the forward viewing endoscope and the limited enteroscopy-length therapeutic accessories that are currently available. Overall, reported therapeutic success is approximately 70–75% with a complication rate of 3–4%. Alternative approaches include percutaneous transhepatic cholangiography, laparoscopy-assisted ERCP, or surgery. Given the complexity, ERCP in patients with surgically altered anatomy should be performed in close collaboration with body imagers, interventional radiology, and surgical services.

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Abbreviations

ERCP:

Endoscopic retrograde cholangiopancreatography

RYGB:

Roux-en-Y gastric bypass

DBE:

Double-balloon enteroscopy

SBE:

Single-balloon enteroscopy

SE:

Spiral enteroscopy

PTC:

Percutaneous transhepatic cholangiography

EUS-CP:

Endoscopic ultrasound-guided cholangiopancreatography

LA-ERCP:

Laparoscopy-assisted endoscopic retrograde cholangiopancreatography

US:

Ultrasound

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Acknowledgments

We would like to thank M. Alice McKinney for her assistance with surgically altered upper gastrointestinal anatomy illustrations.

Disclosures

None. No financial support was received for this study.

Author information

Author notes

    Authors and Affiliations

    1. Division of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA

      Syed Amer

    2. Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA

      Jennifer L. Horsley-Silva & Rahul Pannala

    3. Division of Radiology, Mayo Clinic, Scottsdale, AZ, USA

      Christine O. Menias

    4. Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA

      Rahul Pannala

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    1. Syed Amer
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    2. Jennifer L. Horsley-Silva
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    Correspondence to Rahul Pannala.

    Additional information

    Syed Amer and Jennifer L. Horsley-Silva contributed equally to this article.

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    Amer, S., Horsley-Silva, J.L., Menias, C.O. et al. Endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy. Abdom Imaging 40, 2921–2931 (2015). https://doi.org/10.1007/s00261-015-0532-7

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