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J Gastroenterol Dig Dis 2017 | Volume 2, Issue 3
World Gastroenterological &
Gastroenterology and Endoscopy
October 30-31, 2017 | Toronto, Canada
World Congress on
Endoscopic retrograde cholangiopancreatography (ERCP)
remains challenging in patients who have undergone
surgical reconstruction of the intestine. In 2001, double-
balloon enteroscope (DBE) was reported by Yamamoto et al
to be an effective procedure for the diagnosis and treatment
of small intestinal lesions. In 2005, DBE-assisted ERCPwas first
successfully by Haruta et al used to treat a late anastomotic
stricture in a patient who undergone biliary reconstruction by
R-Y choledochojejunostomy after liver transplantation. After
that, several studies with long enteroscope have reported
that balloon enteroscope-assisted ERCP (BEA-ERCP) is a safe
and effective procedure with about 75 % of reaching the
blind end. However, long type enteroscope allows us to use
limited number of ERCP devices because of its 200 cm length.
Then short type double balloon enteroscope (DBE) has
been developed by Fujifilm Co., furthermore Olympus Co.
introduce the prototype of short single balloon enteroscope
(SBE) with bigger channel 3.2 mm in diameter. Using short
type SBE, we can diagnose and treat biliopancreatic diseases
with about 90% of reaching the blind end, 90% diagnostic
success rate, and 96% therapeutic success rate, because
short type SBE allows us to use most of ERCP devices, even
with guide-wire equipment. And complication rate is also rare
3% in pancreatitis, 1.5% in perforation, etc. In general, BEA-
ERCP seems to be taken long time, because it is sometimes
difficult to choose right route to the papilla or chodedochal
or pancreatic anastomosis. In order to choose right route,
several techniques such as intralimunal injection of indigo
carmine by Yano et al and CO2 inflation guidance by Iwai
et al have been reported. Furthermore, PTBD rendezvous
technique and improvement of enteroscope such as passive
vending function etc. introduce to shorten the reaching blind
end time (10-21 min), although there are some learning
effect too. The rate of reaching blind end with short type
SBE is 94 % (126/134) in R-Y gastrectomy, 72% (39/54) in R-Y
choledochojejunostomy, 96% (71/74), 96% (71.74) in Child/
Whipple’s resection, and 97% (29/30) in B-II gastrectomy,
respectively. Using long type SBE, we could reach blind end in
94% (15/16) cases which could not be reached by short type
SBE and were mainly cases of R-Y Choledochojejunostomy.
Concerning about therapeutic procedures, we have
sometimes employed electrocautery in case of tight stricture
of anastomosis such as hepaticojejunostomy if guide-wire
passed and EUS-BD with forward-viewing echoendoscope
was performed in case of non-guide-wire passed. In cases
of large bile duct stone, we have made EPLBD and treated
by EHL after inserting SBE (direct cholangioscopy) into the
bile duct. Finally remaining difficult cases, which we could
not treated by SBE because of un-reaching blind end, were
treated by EUS-HGS route.
e:
Endoscopic management of bilio-pancreatic diseases in surgically altered patients
Mitsuhiro Kida
Kitasato University, Japan