The Roux-en-Y gastric bypass (RYGB) accounts for more than 60% of bariatric procedures performed in the United States today. The RYGB anatomy poses particular challenges to interventional endoscopists who intend to access the papilla. Deep enteroscopy-assisted endoscopic retrograde cholangiopancreatography seems to be the least invasive technique for this purpose, and is often the best initial choice. However, considerable experience is needed to optimize the success rate of reaching the biliopancreatic limb, with subsequent successful cannulation, and which approach is taken should be determined on a case-by-case basis.
The obesity epidemic and the high prevalence of obesity-related comorbidities have received considerable attention, and are currently considered a worldwide public health priority. Behavioral and pharmacologic treatments have had limited efficacy, particularly in the setting of severe obesity. Surgical treatment of obesity has been established to be the only effective means of significant and sustainable weight loss in this patient population. Equally important, bariatric surgery can significantly improve obesity-related comorbidities and quality of life. Within the past decade, the volume of bariatric surgery has increased by 900% in the United States and 350% in other parts of the world.
The Roux-en-Y gastric bypass (RYGB) accounts for more than 60% of bariatric procedures performed in the United States today. The first step during RYGB surgeries is creation of a small gastric pouch approximately 30 mL in size. The jejunum is then divided into upper (biliopancreatic) and lower limbs, typically 30 to 60 cm distal to the ligament of Treitz, although some surgeons create much longer biliopancreatic limbs (100–150 cm). The Roux limb is brought up to the level of the gastric pouch and anastomosed to the gastric pouch (gastrojejunostomy). The biliopancreatic limb and Roux limb are connected via a jejunojejunostomy 75 to 150 cm distal to the gastrojejunostomy. In fact, the longest Roux limbs are encountered in those created as part of RYGB procedures.
The performance of endoscopic retrograde cholangiopancreatography (ERCP) in the setting of RYGB is challenging. The first major challenge is the length of the bowel that has to be traversed to access the papilla. This frequently necessitates the use of forward-viewing enteroscopes to reach the papilla. The use of forward-viewing scopes to access the papilla and perform ERCP in these patients represents a challenge itself. The papillary orifice is not routinely visible using forward-viewing instruments. When the orifice is visible, its alignment with the scope and instruments used during ERCP is often suboptimal, especially in view of the absence of an elevator. Another hindrance is the sharp angulation at the jejunojejunostomy, which often requires an almost 180-degree U-turn to access the pancreaticobiliary limb. Finally, the performance of ERCP using enteroscopes requires the use of many specialized accessories, the availability of which may be limited in some markets.
Indications
Indications for ERCP in patients who are post-RYGB surgery encompass all indications for the procedure as in patients with native gastrointestinal anatomy. Some diseases, however, occur more often in RYGB patients. Rapid weight loss creates a lithogenic state and is associated with an increased risk of cholelithiasis. This results from increased bile mucin content and bile calcium concentration in the gallbladder during periods of weight loss. Although the gallbladder is often removed during open RYGB, this is not a routine practice during laparoscopic RYGB. Also, papillary stenosis can be seen in this population, and often requires ERCP with endoscopic biliary sphincterotomy.
Methods of accessing the papilla in RYGB patients
Multiple studies have assessed the use of different techniques to access the papilla in patients with altered anatomy. Although some of these studies investigated patients who have undergone Roux-en-Y reconstructive surgeries, none focused on bariatric RYGB patients. The RYGB surgical anatomy represents a particular challenge to endoscopists who intend to perform papillary interventions because it entails creation of the longest Roux limbs for purposes of weight loss.
ERCP Using Duodenoscopes and Colonoscopes
The side-viewing duodenoscope is the optimal instrument to perform ERCP because of the location of the ampulla on the medial side of the duodenum. Nevertheless, advancement of the duodenoscope through the anatomic route to reach the ampulla in RYGB patients is almost impossible. Hintze and colleagues reported a failure rate of 67% to reach the ampulla using a duodenoscope in patients with Roux-en-Y anatomy (none post-RYGB). This failure rate is expected to be higher in RYGB patients who usually have longer Roux limbs. Wright and colleagues used a pediatric colonoscope to access the afferent limb and place a guide wire, followed by advancement of the duodenoscope over the wire using fluoroscopic guidance. ERCP was possible in 45% of patients with RYGB anatomy. Therefore, the use of a duodenoscope to perform ERCP in RYGB patients frequently fails. In addition, this technique should be attempted only by experienced endoscopists because of the challenge of navigating a side-viewing instrument through altered anatomy, for a long distance, through anastomoses, and through sharp angulations.
ERCP Using Double-Balloon Enteroscopy
Three types of endoscopes (and overtubes) for double-balloon enteroscopy (DBE) (Fujinon, Inc, Saitama, Japan) are currently available. The EN-450P5 (effective length 2 m, outer diameter 8.5 mm, biopsy channel diameter 2.2 mm) is mainly used for diagnostic purposes. The EN-450T5 (effective length 2 m, outer diameter 9.4 mm, biopsy channel diameter 2.8 mm) can be used for diagnostic and therapeutic indications. The EC-450BI5 (effective length 1.52 m, outer diameter 9.4 mm, biopsy channel diameter 2.8 mm) has a shorter working length. This shorter scope is ideal to use for accessing the papilla in RYGB patients because all standard ERCP accessories, some of which are too short to use with a 2-m scope, can be used. The DBE enteroscope is advanced in the small bowel as previously described by Yamamoto and colleagues.
Sakai and colleagues were the first to use DBE for the evaluation of the bypassed stomach after RYGB. Since then, multiple studies have described the use of DBE to facilitate the performance of ERCP in patients with Roux-en-Y anatomy. These studies reported a high success rate of greater than 90% for reaching the biliopancreatic limb and an 80% success rate for ERCP. However, most of the subjects studied were not bariatric RYGB patients. Emmett and Mallat performed DBE-ERCP in patients with Roux-en-Y anatomy. The ampulla was reached in all patients after Roux-en-Y and ERCP was successful in 88% of these patients. Although these results are encouraging, most of the reported data and experience comes from studying patients with hepaticojejunostomy. These patients have shorter Roux limbs. In addition, cannulation of hepaticojejunostomy anastomosis is less technically demanding than cannulation of a native ampulla, especially when these are approached in retrograde fashion.
ERCP Using Single-Balloon Enteroscopy
Single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) are the latest breakthrough techniques in endoscopic evaluation of the small bowel. SBE has been introduced to simplify the technique of push-and-pull enteroscopy. Some investigators have suggested that SBE is more intuitive to learn and possibly more efficient than DBE. The potential advantages of SBE over DBE include shorter setup time, 1 balloon cycle requirement instead of 2, a less cumbersome balloon control panel, a less floppy scope, and the use of a nonlatex balloon. The single-balloon overtube (Olympus Optical, Tokyo, Japan) is used for SBE procedures. The overtube has one balloon at its tip and both the balloon and overtube are made of silicone. The overtube measures 140 cm in length and has a diameter of 13.2 mm. The enteroscope is advanced to its maximal position without looping and the overtube is then advanced to the distal portion of the enteroscope. The scope tip is either deflected into a U-turn to hook onto the SB mucosa or the mucosa is suctioned to stabilize the scope position. After inflating the balloon, the assembly is withdrawn. This series of maneuvers is then repeated until the anatomic area of interest is reached or when the endoscopist deems further maneuvers will not result in significant advancement of the scope.
Few studies, none of which was dedicated to study RYGB patients, have evaluated the use of SBE in patients with Roux-en-Y anatomy. Itoi and colleagues evaluated the usefulness of SBE-ERCP in 11 patients with Roux-en-Y anastomosis, none of which represented RYGB anatomy. The papilla was reached in 91% of these patients and ERCP was successfully performed in 73% of them. Dellon and colleagues reported on 4 patients with Roux-en-Y anatomy who underwent SBE. One patient after RYGB underwent successful SBE-ERCP for abnormal liver enzymes and jaundice. Wang and colleagues assessed the effectiveness of SBE-ERCP in 13 patients with altered anatomy, 6 of whom were post-RYGB. The ampulla was reached and ERCP was successful in 4 of these patients. The ampulla could not be reached on the first attempt in 2 patients because of a tight hairpin turn that was required to reach and intubate the afferent limb from the Roux-en-Y anastomosis. In both patients, a second SBE-ERCP was attempted and was successful.
ERCP Using Spirus Enteroscopy
Spirus enteroscopy (SE) is performed using the Endo-Ease Discovery SB overtube (Spirus Medical, Stoughton, MA, USA). The overtube is made of polyvinyl chloride and measures 118 cm with a 21-cm spiral element at the tip. Advancement is made by clockwise rotation until the point of depth of maximal insertion. The enteroscope is then unlocked from the overtube and advanced as far as possible. The enteroscope is subsequently withdrawn in a similar manner to the previously mentioned “hook-and-suction technique,” while rotating the overtube. This sequence is repeated about 3 times. Withdrawal is performed by counterclockwise rotation of the overtube.
One study published only in abstract form described a single-center experience with SE in 57 patients, 7 of whom were post-RYGB. The excluded stomach was reached in 5 of these patients. No further details were provided.
ERCP Through Gastrostomy or Jejunostomy Tracts
Baron and Vickers were first to describe creation of a surgical gastrostomy to facilitate ERCP in an RYGB patient who had failed an attempt at ERCP using an enteroscope through the anatomic route. Since then, multiple other investigators have described their similar experience with high success rates. The technique involves initial placement of a surgical gastrostomy in the excluded stomach. ERCP is then performed at a later time through a healed gastrostomy tract. The gastrostomy tube is removed, followed by passage of a forward-viewing scope through the tract. Wire-guided Savary dilation of the tract is then performed. The duodenoscope is passed through the dilated tract to the duodenum and ERCP is performed in the usual manner.
Although gastrostomy offers a reliable means to perform ERCP in RYGB patients, this technique is more invasive than the previously described endoscopic techniques, and entails surgical and anesthesia risks. In addition, gastrostomy tubes negatively affect the quality of life of patients and should be removed as soon as repeat ERCP is deemed unnecessary. Another limitation of this technique is that it is sometimes impractical to wait for the gastrostomy tract to mature before performing ERCP (such as in patients with acute cholangitis or severe acute biliary pancreatitis).
Baron described the technique of retrograde placement of percutaneous endoscopic gastrostomy (RPEG) to allow subsequent ERCP in patients with RYGB who have failed prior attempts at ERCP via the anatomic route. With this technique, the endoscope is advanced proximal to the ampulla and into the excluded stomach in retrograde fashion. An area of transillumination and indentation for RPEG is identified and the procedure is then completed in the usual fashion.
Laparoscopic-Assisted ERCP
Laparoscopic-assisted ERCP in RYGB patients refers to the laparoscopic creation of a point of access to the gastric remnant for the duodenoscope to reach the papilla. This technique may be used in patients with RYGB who had failed prior attempts at accessing the papilla using the previously described methods. Although laparoscopic-assisted ERCP is not widely practiced, several recent studies that assessed the use of this technique have reported encouraging results.
Initial surgical access to the abdomen is gained by using a Veress needle. A shielded trocar is inserted, and a laparoscopic examination is then conducted. The ligament of Treitz is identified, which allows identification of the afferent Roux limb. The bowel is then followed distally from the Y connection. The biliopancreatic limb is occluded with a bowel clamp to prevent insufflation of the gastrointestinal tract, which obscures laparoscopic visualization. A 15-mm trocar is introduced into the left upper quadrant through which the sterilized duodenoscope is passed. The endoscopist guides the endoscope through the 15-mm trocar and monitors it as it exits into the peritoneum. The surgeon and endoscopist work together to guide the endoscope into the excluded stomach. Once into the excluded stomach, the endoscope is advanced through the pylorus and positioned in the second duodenum, and ERCP is performed in the usual fashion.
Lopes and colleagues recently reported their experience with laparoscopic-assisted ERCP in 10 patients. Biliary cannulation was successful in 90% of cases. The investigators also recognized and treated 4 internal hernias during laparoscopic examination. All of the hernias were missed on preoperative CT examination. Tension pneumothorax developed in one patient during the procedure, which was caused by an indwelling percutaneous transhepatic cholangiography (PTC) catheter that crossed the diaphragm. This was promptly recognized and treated successfully with chest tube placement.
Methods of accessing the papilla in RYGB patients
Multiple studies have assessed the use of different techniques to access the papilla in patients with altered anatomy. Although some of these studies investigated patients who have undergone Roux-en-Y reconstructive surgeries, none focused on bariatric RYGB patients. The RYGB surgical anatomy represents a particular challenge to endoscopists who intend to perform papillary interventions because it entails creation of the longest Roux limbs for purposes of weight loss.
ERCP Using Duodenoscopes and Colonoscopes
The side-viewing duodenoscope is the optimal instrument to perform ERCP because of the location of the ampulla on the medial side of the duodenum. Nevertheless, advancement of the duodenoscope through the anatomic route to reach the ampulla in RYGB patients is almost impossible. Hintze and colleagues reported a failure rate of 67% to reach the ampulla using a duodenoscope in patients with Roux-en-Y anatomy (none post-RYGB). This failure rate is expected to be higher in RYGB patients who usually have longer Roux limbs. Wright and colleagues used a pediatric colonoscope to access the afferent limb and place a guide wire, followed by advancement of the duodenoscope over the wire using fluoroscopic guidance. ERCP was possible in 45% of patients with RYGB anatomy. Therefore, the use of a duodenoscope to perform ERCP in RYGB patients frequently fails. In addition, this technique should be attempted only by experienced endoscopists because of the challenge of navigating a side-viewing instrument through altered anatomy, for a long distance, through anastomoses, and through sharp angulations.
ERCP Using Double-Balloon Enteroscopy
Three types of endoscopes (and overtubes) for double-balloon enteroscopy (DBE) (Fujinon, Inc, Saitama, Japan) are currently available. The EN-450P5 (effective length 2 m, outer diameter 8.5 mm, biopsy channel diameter 2.2 mm) is mainly used for diagnostic purposes. The EN-450T5 (effective length 2 m, outer diameter 9.4 mm, biopsy channel diameter 2.8 mm) can be used for diagnostic and therapeutic indications. The EC-450BI5 (effective length 1.52 m, outer diameter 9.4 mm, biopsy channel diameter 2.8 mm) has a shorter working length. This shorter scope is ideal to use for accessing the papilla in RYGB patients because all standard ERCP accessories, some of which are too short to use with a 2-m scope, can be used. The DBE enteroscope is advanced in the small bowel as previously described by Yamamoto and colleagues.
Sakai and colleagues were the first to use DBE for the evaluation of the bypassed stomach after RYGB. Since then, multiple studies have described the use of DBE to facilitate the performance of ERCP in patients with Roux-en-Y anatomy. These studies reported a high success rate of greater than 90% for reaching the biliopancreatic limb and an 80% success rate for ERCP. However, most of the subjects studied were not bariatric RYGB patients. Emmett and Mallat performed DBE-ERCP in patients with Roux-en-Y anatomy. The ampulla was reached in all patients after Roux-en-Y and ERCP was successful in 88% of these patients. Although these results are encouraging, most of the reported data and experience comes from studying patients with hepaticojejunostomy. These patients have shorter Roux limbs. In addition, cannulation of hepaticojejunostomy anastomosis is less technically demanding than cannulation of a native ampulla, especially when these are approached in retrograde fashion.
ERCP Using Single-Balloon Enteroscopy
Single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) are the latest breakthrough techniques in endoscopic evaluation of the small bowel. SBE has been introduced to simplify the technique of push-and-pull enteroscopy. Some investigators have suggested that SBE is more intuitive to learn and possibly more efficient than DBE. The potential advantages of SBE over DBE include shorter setup time, 1 balloon cycle requirement instead of 2, a less cumbersome balloon control panel, a less floppy scope, and the use of a nonlatex balloon. The single-balloon overtube (Olympus Optical, Tokyo, Japan) is used for SBE procedures. The overtube has one balloon at its tip and both the balloon and overtube are made of silicone. The overtube measures 140 cm in length and has a diameter of 13.2 mm. The enteroscope is advanced to its maximal position without looping and the overtube is then advanced to the distal portion of the enteroscope. The scope tip is either deflected into a U-turn to hook onto the SB mucosa or the mucosa is suctioned to stabilize the scope position. After inflating the balloon, the assembly is withdrawn. This series of maneuvers is then repeated until the anatomic area of interest is reached or when the endoscopist deems further maneuvers will not result in significant advancement of the scope.
Few studies, none of which was dedicated to study RYGB patients, have evaluated the use of SBE in patients with Roux-en-Y anatomy. Itoi and colleagues evaluated the usefulness of SBE-ERCP in 11 patients with Roux-en-Y anastomosis, none of which represented RYGB anatomy. The papilla was reached in 91% of these patients and ERCP was successfully performed in 73% of them. Dellon and colleagues reported on 4 patients with Roux-en-Y anatomy who underwent SBE. One patient after RYGB underwent successful SBE-ERCP for abnormal liver enzymes and jaundice. Wang and colleagues assessed the effectiveness of SBE-ERCP in 13 patients with altered anatomy, 6 of whom were post-RYGB. The ampulla was reached and ERCP was successful in 4 of these patients. The ampulla could not be reached on the first attempt in 2 patients because of a tight hairpin turn that was required to reach and intubate the afferent limb from the Roux-en-Y anastomosis. In both patients, a second SBE-ERCP was attempted and was successful.
ERCP Using Spirus Enteroscopy
Spirus enteroscopy (SE) is performed using the Endo-Ease Discovery SB overtube (Spirus Medical, Stoughton, MA, USA). The overtube is made of polyvinyl chloride and measures 118 cm with a 21-cm spiral element at the tip. Advancement is made by clockwise rotation until the point of depth of maximal insertion. The enteroscope is then unlocked from the overtube and advanced as far as possible. The enteroscope is subsequently withdrawn in a similar manner to the previously mentioned “hook-and-suction technique,” while rotating the overtube. This sequence is repeated about 3 times. Withdrawal is performed by counterclockwise rotation of the overtube.
One study published only in abstract form described a single-center experience with SE in 57 patients, 7 of whom were post-RYGB. The excluded stomach was reached in 5 of these patients. No further details were provided.
ERCP Through Gastrostomy or Jejunostomy Tracts
Baron and Vickers were first to describe creation of a surgical gastrostomy to facilitate ERCP in an RYGB patient who had failed an attempt at ERCP using an enteroscope through the anatomic route. Since then, multiple other investigators have described their similar experience with high success rates. The technique involves initial placement of a surgical gastrostomy in the excluded stomach. ERCP is then performed at a later time through a healed gastrostomy tract. The gastrostomy tube is removed, followed by passage of a forward-viewing scope through the tract. Wire-guided Savary dilation of the tract is then performed. The duodenoscope is passed through the dilated tract to the duodenum and ERCP is performed in the usual manner.
Although gastrostomy offers a reliable means to perform ERCP in RYGB patients, this technique is more invasive than the previously described endoscopic techniques, and entails surgical and anesthesia risks. In addition, gastrostomy tubes negatively affect the quality of life of patients and should be removed as soon as repeat ERCP is deemed unnecessary. Another limitation of this technique is that it is sometimes impractical to wait for the gastrostomy tract to mature before performing ERCP (such as in patients with acute cholangitis or severe acute biliary pancreatitis).
Baron described the technique of retrograde placement of percutaneous endoscopic gastrostomy (RPEG) to allow subsequent ERCP in patients with RYGB who have failed prior attempts at ERCP via the anatomic route. With this technique, the endoscope is advanced proximal to the ampulla and into the excluded stomach in retrograde fashion. An area of transillumination and indentation for RPEG is identified and the procedure is then completed in the usual fashion.
Laparoscopic-Assisted ERCP
Laparoscopic-assisted ERCP in RYGB patients refers to the laparoscopic creation of a point of access to the gastric remnant for the duodenoscope to reach the papilla. This technique may be used in patients with RYGB who had failed prior attempts at accessing the papilla using the previously described methods. Although laparoscopic-assisted ERCP is not widely practiced, several recent studies that assessed the use of this technique have reported encouraging results.
Initial surgical access to the abdomen is gained by using a Veress needle. A shielded trocar is inserted, and a laparoscopic examination is then conducted. The ligament of Treitz is identified, which allows identification of the afferent Roux limb. The bowel is then followed distally from the Y connection. The biliopancreatic limb is occluded with a bowel clamp to prevent insufflation of the gastrointestinal tract, which obscures laparoscopic visualization. A 15-mm trocar is introduced into the left upper quadrant through which the sterilized duodenoscope is passed. The endoscopist guides the endoscope through the 15-mm trocar and monitors it as it exits into the peritoneum. The surgeon and endoscopist work together to guide the endoscope into the excluded stomach. Once into the excluded stomach, the endoscope is advanced through the pylorus and positioned in the second duodenum, and ERCP is performed in the usual fashion.
Lopes and colleagues recently reported their experience with laparoscopic-assisted ERCP in 10 patients. Biliary cannulation was successful in 90% of cases. The investigators also recognized and treated 4 internal hernias during laparoscopic examination. All of the hernias were missed on preoperative CT examination. Tension pneumothorax developed in one patient during the procedure, which was caused by an indwelling percutaneous transhepatic cholangiography (PTC) catheter that crossed the diaphragm. This was promptly recognized and treated successfully with chest tube placement.
Related posts:
Obesity Overview: Epidemiology, Health and Financial Impact, and Guidelines for Qualification for Surgical Therapy
Medical Therapy for Obesity
Presurgical Evaluation and Postoperative Care for the Bariatric Patient
Endoscopic Management of Common Bariatric Surgical Complications
Management of Acute Postoperative Hemorrhage in the Bariatric Patient
Management of Postsurgical Leaks in the Bariatric Patient
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