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Therapeutic peroral direct cholangioscopy using a single balloon enteroscope in patients with Roux-en-Y anastomosis (with videos)

Abstract

Background

Peroral cholangioscopic lithotripsy is a useful procedure in patients with a normal gastrointestinal anatomy who have difficult-to-treat stones. We evaluated the usefulness of peroral direct cholangioscopy (PDCS) using single-balloon enteroscope (SBE) in patients with difficult-to-treat stones who had undergone Roux-en-Y reconstruction.

Methods

Among 118 patients (169 sessions) who underwent SBE-assisted endoscopic retrograde cholangiopancreatography to treat biliary stones after Roux-en-Y reconstruction, patients in whom it was difficult to remove biliary stones via a transpapillary or transanastomotic approach and difficult to switch to ultra-slim endoscope, were retrospectively enrolled. The biliary insertion success rate, procedure success rate, procedure time, and procedural complications were assessed. The SBE was inserted into the bile-duct, first using a free-hand technique, second using a guide wire, and third using the large balloon anchoring and deflation (LBAD) technique.

Results

A total of 11 patients (14 sessions) were enrolled in this study. The biliary insertion success rate was 100%. Bile-duct insertion was performed using a free-hand technique in 4 sessions, a guide wire in 3 sessions (rendezvous technique, 2 sessions), and the LBAD technique in 7 sessions. The procedure success rate was 86% in first session, and 100% in second session. The median procedure time was 81 min (range 49–137). The median procedure time in the bile-duct was 21.5 min (range 6–60). Mild pancreatitis occurred as a complication in one patient. The median follow-up was 528 days (range 282–764). No patient had stone recurrence.

Conclusions

PDCS using SBE is a useful procedure in patients with Roux-en-Y reconstruction. The LBAD technique is an useful technique of inserting SBE into the bile-duct.

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References

  1. 1.

    Shimatani M, Matsushita M, Takaoka M et al (2009) Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy 41(10):849–854

  2. 2.

    Siddiqui AA, Chaaya A, Shelton C et al (2013) Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study. Dig Dis Sci 58(3):858–864

  3. 3.

    Yamauchi H, Kida M, Okuwaki K et al (2013) Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy. World J Gastroenterol 19(11):1728–1735

  4. 4.

    Ishii K, Itoi T, Tonozuka R et al (2016) Balloon enteroscopy-assisted ERCP in patients with Roux-en-Y gastrectomy and intact papillae (with videos). Gastrointest Endosc 83(2):377–386

  5. 5.

    Iwai T, Kida M, Yamauchi H et al (2014) Short-type and conventional single-balloon enteroscopes for endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: single-center experience. Dig Endosc 26(Suppl 2):156–163

  6. 6.

    Skinner M, Popa D, Neumann H et al (2014) ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 46(7):560–572

  7. 7.

    Yamauchi H, Kida M, Imaizumi H et al (2015) Innovations and techniques for balloon-enteroscope-assisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy. World J Gastroenterol 21(21):6460–6469

  8. 8.

    Inamdar S, Slattery E, Sejpal DV et al (2015) Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc 82(1):9–19

  9. 9.

    Binmoeller KF, Brückner M, Thonke F et al (1993) Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy 25:201–206

  10. 10.

    Moon JH, Ko BM, Choi HJ et al (2009) Direct per-oral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones. Am J Gastroenterol 104:2729–2733

  11. 11.

    Itoi T, Sofuni A, Itokawa F et al (2012) Diagnostic and therapeutic peroral direct cholangioscopy in patients with altered GI anatomy (with videos). Gastrointest Endosc 75(2):441–449

  12. 12.

    Matsumoto K, Tsutsumi K, Kato H et al (2016) Effectiveness of peroral direct cholangioscopy using an ultraslim endoscope for the treatment of hepatolithiasis in patients with hepaticojejunostomy (with video). Surg Endosc 30(3):1249–1254

  13. 13.

    Okabe Y, Kuwaki K, Kawano H et al (2010) Direct cholangioscopy using a double-balloon enteroscope: choledochojejunostomy with intraductal biliary carcinoma. Dig Endosc 22(4):319–321

  14. 14.

    Law R, Topazian M, Baron TH (2013) Endoscopic resection of hilar papillomatosis after Whipple procedure for ampullary adenoma. Gastrointest Endosc 78(2):226

  15. 15.

    Kao KT, Batra B (2014) Single-balloon-assisted ERCP with electrohydraulic lithotripsy for the treatment of a bile duct stone in a patient with a hepaticojejunostomy. Gastrointest Endosc 80(6):1173

  16. 16.

    Yamauchi H, Kida M, Miyazawa S et al (2015) Electrohydraulic lithotripsy under peroral direct cholangioscopy using short-type single-balloon enteroscope for large common bile duct stone in patients with Roux-en-Y gastrectomy. Endoscopy 47:E240–E241

  17. 17.

    Hakuta R, Kogure H, Isayama H et al (2015) Electrohydraulic lithotripsy of large bile duct stones under direct cholangioscopy with a double-balloon endoscope. Endoscopy 47:E519–E520

  18. 18.

    Cotton PB, Eisen GM, Aabakken L et al (2010) A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 71(3):446–454

  19. 19.

    Oana S, Shibata S, Matsuda N et al (2015) Efficacy and safety of double-balloon endoscopy-assisted endoscopic papillary large-balloon dilatation for common bile duct stone removal. Dig Liver Dis 47(5):401–404

  20. 20.

    Lee YS, Moon JH, Ko BM et al (2010) Endoscopic closure of a distal common bile duct perforation caused by papillary dilation with a large-diameter balloon (with video). Gastrointest Endosc 72(3):616–618

  21. 21.

    Romberg C (2009) Systemic air embolism after ERCP: a case report and review of the literature (with video). Gastrointest Endosc 70(5):1043–1045

  22. 22.

    van Boxel GI, Hommers CE, Dash I et al (2010) Myocardial and cerebral infarction due to massive air embolism following endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 42(Suppl 2):E80–E81

  23. 23.

    Ueki T, Mizuno M, Ota S et al (2010) Carbon dioxide insufflation is useful for obtaining clear images of the bile duct during peroral cholangioscopy (with video). Gastrointest Endosc 71(6):1046–1051

  24. 24.

    Doi S, Yasuda I, Nakashima M et al (2011) Carbon dioxide insufflation vs. conventional saline irrigation for peroral video cholangioscopy. Endoscopy 43(12):1070–1075

  25. 25.

    Itoi T, Nageshwar Reddy D et al (2014) Clinical evaluation of a prototype multi-bending peroral direct cholangioscope. Dig Endosc 26(1):100–107

  26. 26.

    Kondo H, Naitoh I, Nakazawa T et al (2016) Development of fatal systemic gas embolism during direct peroral cholangioscopy under carbon dioxide insufflation. Endoscopy 48(Suppl 1):E215–E216

  27. 27.

    Thosani N, Zubarik RS, Kochar R et al (2016) Prospective evaluation of bacteremia rates and infectious complications among patients undergoing single-operator choledochoscopy during ERCP. Endoscopy 48(5):424–431

Download references

Ackowledgements

The authors thank Olympus Medical Systems (Tokyo, Japan) for providing the prototype instruments used in this study.

Funding

The prototype instruments used in this study were provided by Olympus Medical Systems (Tokyo, Japan).

Author information

Correspondence to Hiroshi Yamauchi.

Ethics declarations

Disclosures

Hiroshi Yamauchi, Mitsuhiro Kida, Kosuke Okuwaki, Shiro Miyazawa, Takaaki Matsumoto, Kazuho Uehara, Eiji Miyata, Rikiya Hasegawa, Toru Kaneko, Issaree Laopeamthong, Yang Lei, Tomohisa Iwai, Hiroshi Imaizumi, and Wasaburo Koizumi have no conflicts of interest or financial ties to disclose.

Electronic supplementary material

Below is the link to the electronic supplementary material.

LBAD technique The papillae was dilated with a 12-mm large balloon, and the balloon was pulled and attached to the enteroscope. Subsequently, the tip of the enteroscope was inserted into the lower bile-duct by the push technique, and the balloon was then removed while deflating. The enteroscope was passively inserted into the bile-duct. Supplementary material 1 (MP4 9737 kb)

EHL for an impacted bile-duct stone and endoscopic retrieval of a proximally migrated biliary stent (Case 3-1) After cholangiography, EPLBD was performed using a 15 mm balloon. A short-type SBE was inserted into the bile-duct using the LBAD technique and showed a proximally migrated biliary stent (that was placed for treatment of acute obstructive suppurative cholangitis before 7 days), an impacted stone, and a bile-duct ulcer associated with the stone. Electrohydraulic lithotripsy (EHL) (Lithotron EL-21 and EHL probes (A 9411) (both manufactured by Walz Elektronik, Rohrdorf, Germany) was performed to crush the impacted stone. The migrated stent was grasped with a snare and was removed along with the scope. Supplementary material 2 (MP4 25493 kb)

A biopsy of an elevated lesion in the bile-duct and biliary dilatation (Case 3-2) One month after stone removal (Video 2), contrast-enhanced CT showed an elevated lesion in the bile-duct. Cholangiography revealed a stricture in the common hepatic duct, and a defect was seen at liver side of stricture. Intraductal ultrasonography showed thickening of the wall at the site of the narrowed bile-duct. A hyperechoic region suggestive of debris was seen at liver side of stricture. A short-type SBE was inserted into the bile-duct, using the LBAD technique. An elevated lesion was seen in the common hepatic duct. Debris was removed with a grasping forceps and a 5-prong forceps. Endoscopic examination suggested that the elevated lesion was benign. However, a biopsy of the elevated lesion was performed to rule out the presence of malignant disease. The stricture was dilated with a balloon. The biliary cast syndrome was diagnosed by histopathological examination of debris tissue. Supplementary material 3 (MP4 22467 kb)

Biliary dilation and stone removal using a 5-prong grasping forceps (Case 7) MRCP showed multiple stones in the left and right intrahepatic bile-ducts. Because the stones could not be removed from the left hepatic duct, direct cholangioscopy was performed and showed a stricture at the origin of the left hepatic duct. The stricture was dilated with a 12-mm balloon. Stones in the left hepatic duct were removed using a 5-prong grasping forceps. After stone removal, an enteroscope was inserted into the left hepatic duct to wash the bile-duct and to confirm the absence of residual stones. Supplementary material 4 (MP4 14787 kb)

Video 1

LBAD technique The papillae was dilated with a 12-mm large balloon, and the balloon was pulled and attached to the enteroscope. Subsequently, the tip of the enteroscope was inserted into the lower bile-duct by the push technique, and the balloon was then removed while deflating. The enteroscope was passively inserted into the bile-duct. Supplementary material 1 (MP4 9737 kb)

Video 2

EHL for an impacted bile-duct stone and endoscopic retrieval of a proximally migrated biliary stent (Case 3-1) After cholangiography, EPLBD was performed using a 15 mm balloon. A short-type SBE was inserted into the bile-duct using the LBAD technique and showed a proximally migrated biliary stent (that was placed for treatment of acute obstructive suppurative cholangitis before 7 days), an impacted stone, and a bile-duct ulcer associated with the stone. Electrohydraulic lithotripsy (EHL) (Lithotron EL-21 and EHL probes (A 9411) (both manufactured by Walz Elektronik, Rohrdorf, Germany) was performed to crush the impacted stone. The migrated stent was grasped with a snare and was removed along with the scope. Supplementary material 2 (MP4 25493 kb)

Video 3

A biopsy of an elevated lesion in the bile-duct and biliary dilatation (Case 3-2) One month after stone removal (Video 2), contrast-enhanced CT showed an elevated lesion in the bile-duct. Cholangiography revealed a stricture in the common hepatic duct, and a defect was seen at liver side of stricture. Intraductal ultrasonography showed thickening of the wall at the site of the narrowed bile-duct. A hyperechoic region suggestive of debris was seen at liver side of stricture. A short-type SBE was inserted into the bile-duct, using the LBAD technique. An elevated lesion was seen in the common hepatic duct. Debris was removed with a grasping forceps and a 5-prong forceps. Endoscopic examination suggested that the elevated lesion was benign. However, a biopsy of the elevated lesion was performed to rule out the presence of malignant disease. The stricture was dilated with a balloon. The biliary cast syndrome was diagnosed by histopathological examination of debris tissue. Supplementary material 3 (MP4 22467 kb)

Video 4

Biliary dilation and stone removal using a 5-prong grasping forceps (Case 7) MRCP showed multiple stones in the left and right intrahepatic bile-ducts. Because the stones could not be removed from the left hepatic duct, direct cholangioscopy was performed and showed a stricture at the origin of the left hepatic duct. The stricture was dilated with a 12-mm balloon. Stones in the left hepatic duct were removed using a 5-prong grasping forceps. After stone removal, an enteroscope was inserted into the left hepatic duct to wash the bile-duct and to confirm the absence of residual stones. Supplementary material 4 (MP4 14787 kb)

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Yamauchi, H., Kida, M., Okuwaki, K. et al. Therapeutic peroral direct cholangioscopy using a single balloon enteroscope in patients with Roux-en-Y anastomosis (with videos). Surg Endosc 32, 498–506 (2018). https://doi.org/10.1007/s00464-017-5742-3

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Keywords

  • ERCP (Endoscopic retrograde cholangiopancreatography)
  • Short type single-balloon enteroscope
  • Altered gastrointestinal anatomy
  • Roux-en-Y
  • Peroral direct cholangioscopy