Background

Deep enteroscopy-assisted ERCP (DEA-ERCP) in post-bariatric Roux-en-Y (RY) anatomy is challenging. Laparoscopy-assisted ERCP (LA-ERCP) and EUS-directed transgastric ERCP (EDGE) are technically easier and faster but are more invasive and morbid procedures. Therefore, we have used DEA-ERCP as our first-line approach, reserving EDGE and LA-ERCP for cases in which adjunctive techniques that cannot be performed through an enteroscope are required (eg, EUS-FNA, sleeve sphincter of Oddi manometry), or DEA-ERCP failures. The 2 main methods for DEA-ERCP are balloon- and spirus-assisted. Current literature on spiral enteroscopy ERCP (SE-ERCP) in bariatric RY anatomy is scant with low success rates reported. Our center has nearly exclusively used SE-ERCP for bariatric patients. Here, we report one of the largest such series to date.

Methods

This is a retrospective cohort study of consecutive patients with bariatric-length RY anatomy who had SE-ERCP from December 2009 to October 2016 at a tertiary care center, by one operator (S.N.S.). Primary outcomes included success at reaching the papilla, cannulation success, success of desired therapeutic intervention, and overall SE-ERCP success.

Results

Thirty-five SE-ERCPs were performed (28 in bariatric RY gastric bypass and 7 other long-limb RY surgical reconstructions). The papilla was reached in 86% (30/35) of cases. Cannulation success in patients in whom deep cannulation was indicated (28/30) was 100% (28/28 cases, including the 24 cases with native papilla). Therapeutic ERCP success was 100% (28/28). Overall SE-ERCP success was 86% (30/35). Median length of stay was 3 days. Median procedure time was 189 minutes. Reasons for SE-ERCP failures included RY anastomosis stricture, adhesions (2), long Roux limb, and redundant small bowel. Two of these patients underwent interventional radiology-guided percutaneous biliary drainage, 2 patients had laparoscopy-assisted ERCP, and 1 patient had EUS-guided antegrade cholangioscopy with sphincteroplasty and stone clearance. There were no adverse events.

Conclusion

With sufficient allotted time (median procedure time ∼3 hours) and high operator experience (a single-operator volume that exceeds that of other published series), SE-ERCP is safe and effective in bariatric, long-limb RY patients with an overall success rate of 86%, which is higher than previously reported.

中文翻译：

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肥胖肠长度Roux-en-Y解剖学中的螺旋肠镜辅助ERCP：大型单中心研究和文献复习（带视频）

背景

肠道后Roux-en-Y（RY）解剖学中的深肠镜辅助ERCP（DEA-ERCP）具有挑战性。腹腔镜辅助的ERCP（LA-ERCP）和EUS引导的经胃ERCP（EDGE）在技术上更容易，更快捷，但更具侵入性和病态性。因此，我们使用DEA-ERCP作为一线方法，在需要通过肠镜无法执行的辅助技术（例如EUS-FNA，Oddi测压袖套括约肌）的情况下，保留EDGE和LA-ERCP，或DEA-ERCP故障。DEA-ERCP的两种主要方法是气囊和螺旋辅助。肥胖RY解剖学中关于螺旋肠镜ERCP（SE-ERCP）的最新文献很少，报道的成功率很低。我们中心几乎将SE-ERCP用于肥胖患者。在这里，我们报告了迄今为止最大的此类系列之一。

方法

这是一项回顾性队列研究，该研究由一名操作者（SNS）对三名肥胖期长的RY解剖结构连续的患者进行了研究，这些患者于2009年12月至2016年10月在三级护理中心接受SE-ERCP治疗。主要结果包括达到乳头的成功率，插管成功率，所需治疗干预的成功率以及SE-ERCP的总体成功率。

结果

进行了35例SE-ERCP（减肥RY胃旁路手术中28例，其他7条长肢RY外科手术重建中）。86％（30/35）的病例达到了乳头状。指示进行深层插管（28/30）的患者插管成功率为100％（28/28例，包括24例天然乳头）。治疗性ERCP成功率为100％（28/28）。SE-ERCP的总体成功率为86％（30/35）。平均住院天数为3天。中位手术时间为189分钟。SE-ERCP失败的原因包括RY吻合口狭窄，粘连（2），长Roux肢和多余的小肠。这些患者中有2例接受了放射学指导的经皮胆道引流，2例接受了腹腔镜辅助的ERCP，1例接受了EUS引导的顺行胆管镜检查，同时进行了括约肌成形术和结石清除术。

结论

SE-ERCP具有足够的分配时间（中位手术时间约为3小时），并且具有较高的操作经验（单人操作量超过了其他已发表的系列文章），在肥胖，长肢RY患者中是安全有效的，总体上取得了成功率为86％，高于以前的报告。