Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Keywords: : Endoscopic retrograde cholangiopancreatography; Endoscopic retrograde cholangiopancreatography in Billroth II; Endoscopic retrograde cholangiopancreatography post-Whipple; Endoscopic ultrasonography-guided endoscopic retrograde cholangiopancreatography; Surgically altered anatomy.

Figure 1

Billroth II gastrectomy and variations of reconstruction. A: Antiperistaltic type. The entry of the afferent limb is located near the lesser curvature; B: Isoperistaltic type. The entry site is located near the greater curvature; C: Retrocolic reconstruction. The afferent limb is shorter than that in antecolic reconstruction; D: Antecolic reconstruction. The afferent limb is significantly longer than that in retrocolic reconstruction; E: Roux-en-Y reconstruction involves the longest limb among all Billroth II gastrectomy techniques; F: Braun jejunojejunostomy anastomosis creates a confusing endoscopic view to reach the afferent limb.

Figure 2

Various reconstructions of pancreaticoduodenectomy (Whipple’s procedure). A: Conventional Whipple’s procedure; The afferent limb is near the lesser curve; B: Pylorus-preserving pancreaticoduodenectomy; C: Braun anastomosis may create a confusing endoscopic view.

Figure 3

Other types of reconstruction. A: Roux-en-Y gastric bypass; B: Hepaticojejunostomy in liver transplant, pancreaticobiliary maljunction, or bile duct cancer.

Figure 4

Technique to identify afferent limb. A: Intraluminal indigo carmine injection; B: CO₂ insufflation guidance.

Figure 5

Endoscopic EUS-guided ERCP and laparoscopic-assisted ERCP in Roux-en-Y gastric bypass. A: EUS-guided transgastric fistula by luminal-apposing metallic stents; B: EUS-guided jejunogastrostomy stent with conventional ERCP; C: EUS-directed transgastric ERCP for Roux-en-Y reconstruction; D: EUS-guided sutured gastropexy for transgastric ERCP; E: Laparoscopic-assisted ERCP. ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Ultrasonography.