Usefulness of endoscopic nasobiliary drainage-guided ERCP in patients with surgically altered anatomy (with video)

Abstract

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is one of the most challenging endoscopic procedures. Although single- or double-balloon endoscopes have been widely used, reaching the papilla of Vater (hepaticojejunostomy/pancreaticojejunostomy site) is often difficult. For patients in whom treatment cannot be completed in a single session, we placed endoscopic nasobiliary drainage (ENBD) at the end of the procedure; in the second session, the scope was inserted following ENBD placement. Patients and methods Three patients with surgically altered anatomy and who underwent ENBD-guided ERCP were retrospectively examined using the medical records. Results There were two men and one woman, with an average age of 75 years. The surgical procedure were distal gastrectomy and Roux-en-Y reconstruction in all patients. The diagnosis were choledocholithiasis in two and bile duct stricture in one. Average time to reach the papilla was 50 minutes (range, 21-102) for the first ERCP and was shortened to 11 minutes (range, 5-17) for the second session under an indwelling ENBD. Treatment was successful in all patients without complications. Conclusion ENBD-guided ERCP in patients with surgically altered anatomy was a useful method that facilitated scope insertion and shortened the procedure time.

Fig. 1

In Case 1, Aa 81-year-old woman with a history of distal gastrectomy and Roux-en-Y reconstruction was admitted for common bile duct stones and cholecystitis. ERCP using short-type single-balloon endoscope (SIF-290S, Olympus Medical Systems, Tokyo, Japan) was performed. a For the first ERCP, time to reach the papilla was 21 minutes. Cholangiography showed numerous stones in the common bile duct. b Complete stone extraction was impossible during the first session, and a 6-Fr pigtail-type ENBD was placed at the end of the procedure. c During the second session with the ENBD in place, the scope was able to reach the papilla in 5 minutes. d The anastomosis was easily recognized under an indwelling ENBD. e The ampulla of Vater with the ENBD in place.

Fig. 2

In Case 2, a 73-year-old man with a history of distal gastrectomy Roux-en-Y reconstruction for gastric cancer. The patient was transported from a previous doctor owing to obstructive jaundice. a First ERCP was performed using short-type single-balloon endoscope. Owing to a high degree of adhesion, it took to 102 minutes to reach the papilla. Cholangiography shows stricture in the middle bile duct. b A 6-Fr ENBD was placed for reducing jaundice. c A second ERCP was performed for internal drainage. After insertion of the scope along the ENBD, it reached the papilla in 17 minutes. A metallic stent was placed, and jaundice improved. d The scope could be inserted smoothly using ENBD as a guide. e Advancement of the catheter along the ENBD successfully allowed deep cannulation of the bile duct.

Fig. 3

In Case 3, 70-year-old man with a history of distal gastrectomy Roux-en-Y reconstruction was admitted for common bile duct stones and cholangitis. a For the first ERCP, time to reach the papilla was 27 minutes. Cholangiography shows multiple stones in the common bile duct. b Complete stone extraction was impossible during the first session, and a 6-Fr pigtail-type ENBD was placed. c ,  d ,  e Three days later, a second ERCP was performed. The scope was inserted with the ENBD in place. The time to reach the papilla was shortened to 11 minutes.