Surgical Endoscopy

, Volume 27, Issue 8, pp 2894–2899 | Cite as

ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery

  • Eun Kwang Choi
  • Michael V. Chiorean
  • Gregory A. Coté
  • Ihab El Hajj
  • Darren Ballard
  • Evan L. Fogel
  • James L. Watkins
  • Lee McHenry
  • Stuart Sherman
  • Glen A. LehmanEmail author



Roux-en-Y gastric bypass (RYGB) is the most common bariatric surgery. The performance of ERCP in bariatric RYGB is challenging due to the long Roux limb. We herein compared the indications and technical outcomes of ERCP via percutaneous gastrostomy (GERCP) and double balloon enteroscopy (DBERCP) for patients with prior bariatric RYGB anatomy.


Between December 2005 and November 2011, consecutive ERCP patients who had undergone RYGB were identified using a prospectively maintained electronic ERCP database. Medical records were abstracted for ERCP indications and outcomes. In most cases, the gastrostomy was done by either laparoscopic or open surgery and allowed to mature at least 1 month before performing ERCP. The choice of route for ERCP was at discretion of managing physician.


Forty-four patients (F = 42) with GERCP and 28 patients (F = 26) with DBERCP were identified. The mean age was younger in GERCP than DBERCP (44.8 vs. 56.1, p < 0.001). GERCP patients were more likely to have suspected sphincter of Oddi dysfunction (77 %) as the primary indication whereas DBERCP was suspected CBD stone (57 %). The mean total number of sessions/patient in GERCP and DBERCP was 1.7 ± 1.0 and 1.1 ± 0.4, respectively (p = 0.004). GERCP access to the major papilla was successful in all but two (97 %), whereas duct cannulation and interventions were successful in all. In DBERCP, the success rate of accessing major papilla, cannulation and therapeutic intervention was 78, 63, 56 %, respectively. There was one (3.1 %) post-ERCP pancreatitis in DBERCP. Complications occurred in 11 GERCP procedures (14.5 %) and 10 were related to the gastrostomy. This was significantly higher than that of DBERCP (p = 0.022).


GERCP is more effective than DBERCP in gaining access to the pancreatobiliary tree in patients with RYGB, but it is hindered by the gastrostomy maturation delay and a higher morbidity. Technical improvements in each method are needed.


Roux-en-Y gastric bypass surgery Endoscopic retrograde cholangiopancreatography Double balloon enteroscopy Surgical gastrostomy 



Eun Kwang Choi, Ihab El Hajj, Darren Ballard, Evan L. Fogel, and James L. Watkins have no conflict of interest or financial ties to disclose. Michael V. Chiorean, MD: Advisory Committees or Review Panels: Corporation Abbott, UCB, Inc.; Speaking and Teaching: Abbott, UCB, Inc., Centocor, Inc., Given Imaging. Gregory A. Coté, MD: Advisory Committees or Review Panels: Abbott Laboratories, Olympus America, Inc.; Consulting: Boston Scientific Corporation. Lee McHenry, MD: Consulting: ConMed Endoscopic Technologies, Boston Scientific Corporation. Stuart Sherman, MD: Speaking and teaching: Boston Scientific, Cook, Olympus America; Consulting: Repligen Corporation. Glen A. Lehman, MD: Consulting: Cook Medical, Olympus; Grant/Research support: Medigus Inc., SafeStitch, Cook Medical; Speaking and Teaching: Cook Medical, Olympus


  1. 1.
    Prentice AM (2006) The emerging epidemic of obesity in developing countries. Int J Epidemiol 35:93–99PubMedCrossRefGoogle Scholar
  2. 2.
    Ogden CL, Yanovski SZ, Carroll MD, Flegal KM (2007) The epidemiology of obesity. Gastroenterology 132:2087–2102PubMedCrossRefGoogle Scholar
  3. 3.
    Nguyen DM, El-Serag HB (2009) The big burden of obesity. Gastrointest Endosc 70:752–757PubMedCrossRefGoogle Scholar
  4. 4.
    Needleman BJ, Happel LC (2008) Bariatric surgery: choosing the optimal procedure. Surg Clin North Am 88:991–1007PubMedCrossRefGoogle Scholar
  5. 5.
    Santry HP, Gillen DL, Lauderdale DS (2005) Trends in bariatric surgical procedures. JAMA 294:1909–1917PubMedCrossRefGoogle Scholar
  6. 6.
    Khashab MA, Okolo PI III (2011) Accessing the pancreatobiliary limb and ERCP in the bariatric patient. Gastrointest Endosc Clin N Am 21:305–313PubMedCrossRefGoogle Scholar
  7. 7.
    Ross AS (2009) Endoscopic retrograde cholangiopancreatography in the surgically modified gastrointestinal tract. Gastrointest Endosc Clin N Am 19:497–507PubMedCrossRefGoogle Scholar
  8. 8.
    Stellato TA, Crouse C, Hallowell PT (2003) Bariatric surgery: creating new challenges for the endoscopist. Gastrointest Endosc 57:86–94PubMedCrossRefGoogle Scholar
  9. 9.
    Lopes TL, Wilcox CM (2010) Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Gastroenterol Clin North Am 39:99–107PubMedCrossRefGoogle Scholar
  10. 10.
    Baron TH, Vickers SM (1998) Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Gastrointest Endosc 48:640–641PubMedCrossRefGoogle Scholar
  11. 11.
    Yamamoto H, Sekine Y, Sato Y, Higashizawa T, Miyata T, Iino S, Ido K, Sugano K (2001) Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 53:216–220PubMedCrossRefGoogle Scholar
  12. 12.
    Aabakken L, Bretthauer M, Line PD (2007) Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy 39:1068–1071PubMedCrossRefGoogle Scholar
  13. 13.
    Emmett DS, Mallat DB (2007) Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series. Gastrointest Endosc 66:1038–1041PubMedCrossRefGoogle Scholar
  14. 14.
    Cotton PB, Lehman GA, Vennes J, Geenen JE, Russell RC, Meyers WC, Liguory C, Nickl N (1991) Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 37:383–393PubMedCrossRefGoogle Scholar
  15. 15.
    Steinbrook R (2004) Surgery for severe obesity. N Engl J Med 350:1075–1079PubMedCrossRefGoogle Scholar
  16. 16.
    Trus TL, Pope GD, Finlayson SR (2005) National trends in utilization and outcomes of bariatric surgery. Surg Endosc 19:616–620PubMedCrossRefGoogle Scholar
  17. 17.
    Byrne TK (2001) Complications of surgery for obesity. Surg Clin North Am 81:1181–1193PubMedCrossRefGoogle Scholar
  18. 18.
    Patel JA, Patel NA, Shinde T, Uchal M, Dhawan MK, Kulkarni A, Colella JJ (2008) Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature. Am Surg 74:689–693PubMedGoogle Scholar
  19. 19.
    Saleem A, Levy MJ, Petersen BT, Que FG, Baron TH (2011) Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 16:203–208PubMedCrossRefGoogle Scholar
  20. 20.
    Lawrence C, Cotton PB, Romagnuolo J, Payne KM, Rawls E, Hawes RH (2007) Small prophylactic pancreatic duct stents: an assessment of spontaneous passage and stent-induced ductal abnormalities. Endoscopy 39:1082–1085PubMedCrossRefGoogle Scholar
  21. 21.
    Gutierrez JM, Lederer H, Krook JC, Kinney TP, Freeman ML, Jensen EH (2009) Surgical gastrostomy for pancreatobiliary and duodenal access following Roux-en-Y gastric bypass. J Gastrointest Surg 13:2170–2175PubMedCrossRefGoogle Scholar
  22. 22.
    Tekola B, Wang AY, Ramanath M, Burnette B, Ellen K, Schirmer BD, Hallowell PT, Sauer BG, Kahaleh M (2011) Percutaneous gastrostomy tube placement to perform transgastrostomy endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Dig Dis Sci 56:3364–3369PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Eun Kwang Choi
    • 1
  • Michael V. Chiorean
    • 1
  • Gregory A. Coté
    • 1
  • Ihab El Hajj
    • 1
  • Darren Ballard
    • 1
  • Evan L. Fogel
    • 1
  • James L. Watkins
    • 1
  • Lee McHenry
    • 1
  • Stuart Sherman
    • 1
  • Glen A. Lehman
    • 1
    Email author
  1. 1.Division of Gastroenterology/Hepatology, Department of MedicineIndiana University Medical CenterIndianapolisUSA

Personalised recommendations