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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.
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).
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.
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.
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 1MRCP confirmed a stricture of the bilioenteric anastomosis (arrow).
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).
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.
PowerSpiral-assisted therapeutic ERCP in a patient with bilioenteric anastomosis and Roux-en-Y reconstructive surgery after duodenum-preserving pancreatic head resection. The picture shows the novel motorized spiral enteroscope (PSF-1) with integrated electric motor and rotatable short disposable spiral overtube attached to the insertion tube portion.
References
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).
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