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Motorized spiral enteroscopy–assisted ERCP after Roux-en-Y reconstructive surgery and bilioenteric anastomosis: first clinical case

Open AccessPublished:May 14, 2020DOI:https://doi.org/10.1016/j.vgie.2020.03.016

      Abbreviation:

      DAE (device-assisted enteroscopy)
      ERCP procedures in patients with surgically altered anatomy are often challenging because Roux-en-Y reconstructive surgery usually excludes the biliopancreatic system from a conventional endoscopic approach. The advent of device-assisted enteroscopy (DAE) using double- and single-balloon enteroscopy and spiral enteroscopy substantially improved the efficacy of endoscopic treatment after all types of Roux-en-Y reconstructions.
      • Shah R.J.
      • Smolkin M.
      • Yen R.
      • et al.
      A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video).
      ,
      • Skinner M.
      • Popa D.
      • Neumann H.
      • et al.
      ERCP with the overtube-assisted enteroscopy technique: a systematic review.
      However, insertion of the enteroscope is still often cumbersome and time consuming, and therapeutic success rates of ERCP are limited by reduced maneuverability of the endoscope and unstable position in front of the papilla, the limited diameter of the working channel, and availability of instruments with an appropriate length.

      Methods

      Since 2015, the novel motorized spiral enteroscope, PowerSpiral Enteroscopy (PSF-1; Olympus Medical Systems Corporation, Tokyo, Japan) has been evaluated in prospective clinical trials by our group and shown to be safe and effective for deep enteroscopy.
      • Beyna T.
      • Schneider M.
      • Pullmann D.
      • et al.
      Motorized spiral colonoscopy: a first single-center feasibility trial.
      • Neuhaus H.
      • Beyna T.
      • Schneider M.
      • et al.
      Novel motorized spiral enteroscopy: first clinical case.
      • Beyna T.
      • Arvanitakis M.
      • Schneider M.
      • et al.
      PowerSpiral Enteroscopy: first prospective bi-centric clinical trial.
      Currently, no published data exist on its use in patients with surgically altered anatomy, in particular for biliopancreatic interventions in patients after Roux-en-Y reconstructive surgery. Specifications of the endoscope using motorized spiral locomotion technology are described in detail in previous publications by our group.
      • Beyna T.
      • Schneider M.
      • Pullmann D.
      • et al.
      Motorized spiral colonoscopy: a first single-center feasibility trial.
      ,
      • Neuhaus H.
      • Beyna T.
      • Schneider M.
      • et al.
      Novel motorized spiral enteroscopy: first clinical case.
      Speed, depth and control of insertion, the short length of 168 cm, and a 3.2-mm working channel, which allow the use of standard ERCP instruments, offer potential advantages compared with standard DAE and may render future complex DAE-ERCP procedures easier, faster, and more efficient.

      Case presentation

      A 78-year-old man presented with obstructive jaundice 18 months after duodenum-preserving pancreatic head resection because of a large branch-duct intraductal papillary mucinous tumor with Roux-en-Y reconstruction and high bilateral bilioenteric anastomosis. MRCP revealed a biliary anastomotic stricture of the right and left hepatic duct (Fig. 1). ERCP approaches using a standard duodenoscope and push enteroscopy with a pediatric colonoscope failed to reach the site of the anastomosis. DAE-ERCP with ballon dilation therapy was successfully performed using the novel motorized spiral enteroscope with the patient under deep sedation (Fig. 2A-C). Total procedure time was 51 minutes (Fig. 3A-B) . No adverse events, such as mucosal tears, occurred during or after the procedure. Jaundice resolved within days, and the patient was discharged.
      Figure thumbnail gr1
      Figure 1MRCP confirmed a stricture of the bilioenteric anastomosis (arrow).
      Figure thumbnail gr2
      Figure 2A, Magnetic resonance imaging. B, Fluoroscopy with spiral overtube (red arrows) and (C) endoscopic aspect of Roux-en-Y anastomosis with hepatobiliary limb (red arrow).
      Figure thumbnail gr3
      Figure 3Scarred stricture of right and left bilioenteric anastomosis, before (A) and after (B) balloon dilatation.

      Conclusion

      The current case represents the first published case of PowerSpiral Enteroscopy-ERCP in a patient with altered anatomy, showing successful and rapid enteroscopic access, cannulation, and balloon dilation therapy without need for general anesthesia.

      Disclosure

      Drs Beyna and Neuhaus are consultants for Olympus. All other authors disclosed no financial relationships.

      Supplementary data

      References

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