A 62-year-old gentleman who works as a chiropractor presented with 1 day of fevers, chills and right upper quadrant pain. He had experienced similar symptoms in the past; however, these were always transient. Persistence and profound worsening of his symptoms prompted entry to the emergency room. His physical exam was notable for a fever of 102 °F, scleral icterus, well-healed laparoscopy port entry scars and RUQ abdominal tenderness. He was found to have total bilirubin 3.8, alkaline phosphatase 641, ALT 440 and AST 152. His white blood cell count was elevated at 16,600 with neutrophil predominance. His past medical history was significant for sleep apnea and type II diabetes, both of which had improved to the point of resolution following weight loss from RYGB. After RYGB 2 years prior, he had lost a total of 76 kg (167.2 lbs). In the ER, a diagnosis of acute cholangitis was made. A right upper quadrant ultrasound demonstrated a 14-mm dilated common bile duct without accompanying filling defect. A CT scan of the abdomen demonstrated the aforementioned biliary dilatation and post-surgical changes. He was not enthusiastic about a percutaneous biliary procedure and was referred for consideration of ERCP. His surgical records were reviewed, revealing a standard laparoscopic gastric bypass. Following administration of intravenous fluids and antibiotics, deep enteroscopy with ERCP was planned. He was orotracheally intubated and placed in supine position for ERCP examination.

In contrast to RYGB, a standard duodenoscope or forward-viewing pediatric colonoscope readily accesses the afferent limb in most patients with Billroth II anatomy depending on the available expertise. In a single-center study of 855 ERCPs in 537 patients with Billroth II, all procedures began with a standard duodenoscope, and the duodenal stump and papilla were identified 89 % (477/537) of the time. There was a 2 % (11/537) jejunum perforation rate [1]. Therefore, most patients with Billroth II anatomy can be approached using a standard duodenoscope or, as an alternative, a pediatric colonoscope. Standard colonoscope insertion techniques including loop reduction, abdominal pressure and turning the patient may aid in Billroth II and other surgical anatomies.

Similarly, in Whipple patients, the area of the pancreatobiliary-enteric anastomoses in the afferent limb is successfully reached in 86–93 % by using the duodenoscope in 76 % of cases and the rest accessed with a gastroscope and adult or pediatric colonoscope [2–4]. Complications occurred in 1 % consisting of conservatively managed retroperitoneal perforation . The challenges the endoscopist face in reaching the anastomoses in Whipple patients include entering the afferent limb and advancing to the anastomoses. Tips to aid in entering and reaching the anastomoses include changing to a forward-viewing endoscope , application of abdominal pressure to prevent endoscope looping, changing the patient’s position, inserting a stiffening wire (Enteroscope stiffening device, Zutron Medical, Lenexa, KS) into the accessory channel to stiffen the scope and tattooing the entrance to the afferent limb.

Patients with a RYGB will require an alternative method to reach the afferent limb due to its long length. Device-assisted enteroscopy (DAE) with double balloon (DBE), short double balloon, single balloon (SBE) and spiral enteroscopy (SE) is one such method. It has improved our ability to reach the ampulla or bilioenteric anastomosis to perform therapy in RYGB patients, although it has limitations. Several reports of DAE-ERCP using DBE, short double balloon and SBE in patients with altered anatomy have been published in the literature with success rates ranging from 60 to 95 %. A multicenter study of 129 patients with post-surgical anatomy (63 RYGB, 30 with other Roux-en-Y anatomy) who had DAE-ERCP reported that enteroscopy success (visualizing papilla or pancreatobiliary-enteric anastomosis) was achieved in 92 of 129 (71 %). The most common reason for ERCP failure was inability to reach the papilla or pancreatobiliary anastomosis [5]. Despite the possible increased success of reaching the ampulla or pancreatobiliary-enteric anastomosis with DAE-ERCP, this technique is limited due to the absence of an elevator on the enteroscopes and the limited number of enteroscope-compatible ERCP accessories.

In DAE, the use of a balloon or rotating overtube to sequentially reduce and pleat the small bowel over a standard enteroscope allows for deep intubation into the small bowel. During DAE-ERCP, the enteroscope and overtube are advanced through the mouth, across the end-to-side gastrojejunostomy and down the jejunal Roux limb to the jejuno-jejunostomy (Fig. 17.2). To facilitate insertion, low insufflation and sequential inflation/deflation of the overtube balloon accompanied by aggressive pleating of the small bowel should be performed. One challenge at the jejuno-jejunal anastomosis is to identify the biliopancreatic limb. At the anastomosis, the endoscopist may visualize 2 lumens. An additional blind-end lumen may be present if the anastomoses have been created in an end-to-side fashion. Though not infallible, the direction of the valvulae conniventes provides a more reliable guide than the presence of bile, which is frequently found in both limbs. The use of fluoroscopy may help identify the biliopancreatic limb. Inadvertent entry into the common channel/efferent limb is often followed by the appearance of multiple intestinal loops in the pelvis on fluoroscopy. An enterogram obtained by injecting contrast via the accessory scope channel can often delineate the likely positions of the biliopancreatic and the common limb. When the common limb is unintentionally intubated, the enteroscope should be withdrawn slowly to the level of the jejuno-jejunostomy. A submucosal tattoo placed at the entrance to the common limb is very helpful to minimize repeated inadvertent entry to that limb.

Often, the biliopancreatic limb is situated at an obtuse angle and requires abdominal counter pressure and good endoscopic technique to enter this limb. A change in the patient’s position may facilitate this process. Passage of a colon length dilator or special length stone extraction balloon into the biliopancreatic limb and inflating the balloon can sometimes simplify entry into this limb by stiffening the enteroscope and providing counter traction. A stiffening wire advanced into the accessory channel of the enteroscope can also aid when looping. The overtube or balloon also acts as a splint which allows negotiation of these acute angulations often found at the gastrojejunal or jejuno-jejunal anastomoses.

Regardless of the approach, it is optimal for the bare enteroscope to enter the limb followed by the overtube. Following an established position in the biliopancreatic limb, pleating of the small bowel assists navigation to the ampulla or bilioenteric anastomosis. In RYGB patients, the pylorus and excluded stomach denote the end of the navigation portion of the procedure as does the blind end of the loop in patients with a Roux-en-Y loop.

Attempts to traverse the afferent limb endoscopically have been made with varying success using the side-viewing duodenoscope, pediatric colonoscope and push-enteroscope. The side-viewing duodenoscope is the preferred endoscope to perform ERCP and duct cannulation. The side view of the papilla is optimal, and the presence of the elevator makes selective duct cannulation easier. However, reaching the ampulla with a duodenoscope is usually unsuccessful in Roux-en-Y anatomy with its long afferent limbs. One study reported the papilla could be reached in only 33 % of patients with Roux-en-Y anatomy using a duodenoscope [6].

The pediatric colonoscope offers the advantage of a longer working length (164 cm) but the forward-view approach and lack of elevator make cannulation of the bile duct challenging. One way to overcome these challenges is to use the pediatric colonoscope or push-enteroscope to reach the papilla, place a long stiff guidewire over which the colonoscope or enteroscope is removed under fluoroscopy and the duodenoscope is subsequently advanced back to the papilla over the wire. A 15- or 18-mm stone extraction balloon can be advanced as far down the afferent limb as possible or into the excluded stomach in RYGB, inflated, and then used to pull the duodenoscope into position. Despite this, success rates remain variable. One study that looked at ERCP using adult or pediatric colonoscopes in patients who had Roux-en-Y hepaticojejunostomy for orthotopic liver transplant reported 29 % failure at reaching the papilla [7]. In another study that employed the guidewire exchange technique in 15 patients with long Roux-en-Y anatomy and a native papilla, the papilla was reached in 67 % (10/15) of patients. The main reason for failure was the inability to advance the duodenoscope to the region of the papilla. In some cases, the duodenoscope was pulled into the afferent limb with a wire-guided balloon passed retrograde into the afferent limb. Cannulation and therapy were primarily performed with a duodenoscope after exploration and placement of a guidewire in the afferent limb with a forward-viewing colonoscope. Of note, the five patients in whom ERCP was not possible all had RYGB anatomy, which highlights the need for alternative methods to perform successful ERCP in this specific patient population [8].

Native papillae are typically readily identified endoscopically. Unfortunately, pancreatobiliary-enteric anastomoses may be very difficult to identify, and simply reaching the end of the afferent limb/Roux-en-Y jejunal loop does not guarantee success. Techniques to aid in identifying the anastomoses include the following: observing for an air cholangiogram on fluoroscopy, carefully examining the antimesenteric side of the afferent limb, filling the jejunum with contrast and repositioning the patient to encourage the contrast to reflux into the ducts, spraying methylene blue in the area where the anastomoses may be located, and injecting secretin to elicit pancreatic secretions (Fig. 17.3). In Whipple patients, the choledochojejunostomy is typically located downstream from the pancreaticojejunostomy, which is found near the end of the afferent limb. The anastomoses are often variable in position and a number of findings may denote their location—the presence of surgical material such as sutures/staples and a frequently bland appearance of the mucosa surrounding the perimeter of the anastomosis (Fig. 17.4). In some instances, high-volume contrast enterography once the endoscope is situated in the periphery of the anastomoses may help identify the position of the anastomoses. The choledochojejunostomy is more readily identified in 85 % of cases and is an end-to-side anastomosis [4]. The sutured pancreaticojejunostomy may be end-to-side or end-to-end and is located in only 42–50 % of patients.

Once the ampulla/pancreatobiliary-enteric anastomosis has been identified, further challenges may await. The ideal situation is having reached these orifices using a duodenoscope through which all the standard ERCP accessories may be used over an elevator. The colonoscope or shorter forward-viewing scopes will allow use of most ERCP accessories, but lack the elevator which can make cannulation difficult. The diameter of the working channel of a pediatric colonoscope will not accept 10-Fr plastic stents. Finally, the 2-m-long single- and double-balloon enteroscope platforms are too long to permit use of standard length sphincterotomes and accessories. A special length stone extraction balloon (Tri-Ex extraction balloon), sphincterotome (Classic Cotton cannulatome), needle knife sphincterotome (Zimmon needle knife papillotome), dilation balloon (Quantum TTC biliary balloon dilator), dilation catheter (Soehendra biliary dilation catheter) and extra-long guidewire (Tracer metro direct guidewire 600 cm long) are all commercially available through Cook Medical (Bloomington, IN) and well suited for use via the 2.8-mm accessory channel of the enteroscope. The short double-balloon enteroscope system uses an enteroscope that is 152 cm long and allows use of standard ERCP accessories. Regardless, the 2.8-mm channel of these enteroscopes limits the size of deployable stents to 7-Fr stents . At the author’s institution, the use of a through-the-scope balloon with an adult colonoscope for these procedures is evolving and permits the placement of the entire armamentarium of stents. This is a single-use balloon catheter advanced through the accessory channel ahead of the scope and requires at least a 3.7 mm channel diameter. After inflating the balloon, the scope is advanced to the balloon while holding counter traction on the balloon catheter, the balloon is deflated and the cycle repeated [9]. Data are awaited on the use of this device in ERCP. If DAE-ERCP is planned, careful preparation must be done beforehand to ensure that the appropriate accessories are available.

Success rates of DAE-ERCP are lower in cases with an intact papilla (50–60 %) versus bilioenteric anastomoses (80–90 %) although a recent large retrospective series suggested comparable cannulation success rates for native papilla and anastomoses [5, 10–13]. Cannulating the ampulla or anastomosis can be technically intricate for multiple reasons including the forward-viewing approach and the absence of an elevator. From the author’s personal experience, manipulating the ampulla to a near 6 o’clock position whenever possible is often helpful as well as approaching the ampulla using the closest en-face position possible. The special length sphincterotomes do not provide much of an arc, and this position enables precise sphincterotome placement using the torque of the endoscope shaft with or without abdominal counter pressure. Placement of a pancreatic duct stent prior to biliary cannulation is a very helpful consideration in patients with altered surgical anatomy as it enables true orientation with regard to the position of the bile duct . This “real-time” orientation facilitates both biliary cannulation and the orientation for sphincterotomy and is superior in most instances to an a priori “guestimate” of the position and orientation of the bile duct. The simplest and safest way to approach performing a sphincterotomy is to place a stent in the bile or pancreatic duct to act as a guide. Sphincterotomy is then performed using a needle knife over the stent. Another relatively straightforward technique which may mitigate some perforation risk is to perform a partial or “small” sphincterotomy in the cephalad direction followed by balloon sphincteroplasty (Fig. 17.5).