Case Report | Open Access
Single Balloon Enteroscopy-Assisted ERCP Using Rendezvous Technique for Sharp Angulation of Roux-en-Y Limb in a Patient with Bile Duct Stones
The acute angulation of Roux-en-Y (R-Y) limb precludes endoscopic access for endoscopic retrograde cholangiopancreatography (ERCP) even using a balloon enteroscopy. Here, we describe a case of successful single balloon enteroscopy (SBE)-assisted ERCP using a rendezvous technique in a patient with sharply angulated R-Y limb in a 79-year-old woman who had bile duct stones. Method. At first, a guidewire was passed antegradely through the major papilla after the needle puncture using percutaneous transhepatic biliary drainage technique. A hydrophilic guidewire with an ERCP catheter was antegradely advanced beyond the Roux limb. After a guidewire was firmly grasped by a snare forceps, it was pulled out of the body, resulting that the enteroscope could advance to the papilla. After papillary dilation, complete removal of bile duct stones was achieved without any procedure-related complication. In conclusion, although further study is needed, SBE-assisted ERCP using a rendezvous technique may have a potential for selected patients.
The acute angulation of Roux-en-Y (R-Y) limb preclude endoscopic access for endoscopic retrograde cholangiopancreatography (ERCP) [1, 2] using even the balloon enteroscopy [3–10]. Here, we describe a case of successful single balloon enteroscopy (SBE)-assisted lithotripsy using a rendezvous technique in a patient with sharply angulated R-Y limb.
2. Case Report
A 79-year-old woman who had total gastrectomy, with R-Y for gastric cancer, was admitted for the treatment of bile duct stones. Although we tried SBE-assisted ERCP (XSIF-Q260Y; Olympus Medical Systems, Tokyo, Japan), an enteroscope could not be advanced to sharply angulated R-Y limb. Three days later, we performed rendezvous technique-assisted SBE using carbon dioxide during the procedure. At first, a guidewire was passed antegradely through the major papilla after the needle puncture using a percutaneous transhepatic biliary drainage (PTBD) technique. A hydrophilic guidewire (Radifocus, Terumo, Tokyo, Japan) with an ERCP catheter was antegradely advanced beyond the Roux limb (Figures 1(a) and 1(b)).
Then the enteroscope was inserted to the Roux limb after a guidewire was found and firmly grasped by a snare forceps, it was pulled out of the body through the working channel of the enteroscope resulting that the enteroscope could advance to the papilla (Figure 2(a)). Cholangiogram revealed bile duct stones (Figure 2(b)).
After papillary dilation using a 15-mm large-balloon (CRE Esophageal/Pyloric, length 5 cm, Boston Scientific Japan, Tokyo, Japan) without sphincterotomy because the major papilla was not well positioned for the sphincterotomy, an enteroscope as a direct cholangioscope was advanced into the bile duct. Direct endoscopic imaging revealed bile duct stones (Figure 3(a)). Bile duct stones were removed using a basket catheter and retrieval balloon. Finally, complete removal of bile duct stones was confirmed by direct endoscopic imaging (Figure 3(b)). Then, a guidewire was pulled out through the working channel. There was no procedure-related complication.
ERCP has evolved into an essential therapeutic modality in patients with pancreaticobiliary diseases. Although successful cannulation of the bile duct is achieved in more than 90% of patients with normal gastrointestinal and biliary anatomy, ERCP in patients with surgically altered anatomy is challenging. Traditional ERCP in patients with a long-limb Roux-en-Y anastomosis is usually not feasible because of the inability to reach the papilla or biliopancreatic anastomosis with a standard side-viewing duodenoscope. A few skilled endoscopists have performed ERCP in such cases using pediatric or adult colonoscopes, or push enteroscopes , or by a percutaneous approach. However, despite using such special endoscopes and techniques, it was often impossible to reach the papilla or the biliopancreatic anastomotic site in patients with Roux-en-Y anastomosis. Furthermore, The acute angle of R-Y limb can be one of major factors of failed enteroscopy-assisted ERCP. When we encounter such patients, we usually change endoscopic therapy to alternative therapies, namely, lithotripsy via PTBD route or surgery. However, they are time-consuming or have relatively high risk of morbidity for elderly people. Recently developed balloon enteroscope systems have made it possible to reach the papilla or biliopancreatoenteric anastomosis site with certainty even in patients with Roux-en-Y surgical anastomoses. Furthermore, the present rendezvous technique for acute angle of R-Y limb could help easily scope insertion into the papilla. To our knowledge, this is the first report on the usefulness of rendezvous technique using single balloon enteroscope in such patients.
In the present case, we performed a large papillary balloon dilation technique without sphincterotomy because the major papilla was not wellpositioned for the sphincterotomy. The procedure of large balloon dilation performed after sphincterotomy has relatively been established for the removal of large bile duct stones without any serious complication [11–16]. Recently, latest article revealed that endoscopic papillary dilation using a large balloon was safe and effective in patients with normal anatomy and large bile duct stones though it was a retrospective analysis . However, the outcome should be evaluated in the near future. Until then, sufficient care should be taken if we use this procedure.
The direct peroral cholangioscopy using an ultraslim has been reported [18, 19]. In the present study, we could completely remove bile duct stones under directly endoscopic imaging using a standard balloon enteroscopy after papillary large-balloon dilation. Although the usefulness of a direct peroral cholagioscopy for the lithotripsy is controversial without performing electric hydraulic or laser lithotripsy, it may have some potential for confirming the residual stones because reintervention for residual stones is tough in patients with R-Y.
In conclusion, although care has to be taken that procedure-related complications can occur and further study is needed, single balloon enteroscopy-assisted ERCP using a rendezvous technique may have a potential for selected patients.
|ERCP:||Endoscopic retrograde cholangiopancreatography|
|PTBD:||Percutaneous transhepatic biliary drainage.|
The authors are indebted to Professor J. Patrick Barron of the Department of International Medical Communication of Tokyo Medical University for his review of this manuscript. The authors have no commercial associations that might pose a conflict of interest in relation to this article.
- G. B. Haber, “Double balloon endoscopy for pancreatic and biliary access in altered anatomy (with videos),” Gastrointestinal Endoscopy, vol. 66, no. 3, supplement 1, pp. S47–S50, 2007.
- P. Chahal, T. H. Baron, M. D. Topazian, B. T. Petersen, M. J. Levy, and C. J. Gostout, “Endoscopic retrograde cholangiopancreatography in post-Whipple patients,” Endoscopy, vol. 38, no. 12, pp. 1241–1245, 2006.
- H. Haruta, H. Yamamoto, K. Mizuta et al., “A case of successful enteroscopic balloon dilation for late anastomotic stricture of choledochojejunostomy after living donor liver transplantation,” Liver Transplantation, vol. 11, no. 12, pp. 1608–1610, 2005.
- S. Mehdizadeh, A. Ross, L. Gerson et al., “What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers,” Gastrointestinal Endoscopy, vol. 64, no. 5, pp. 740–750, 2006.
- L. Aabakken, M. Bretthauer, and P. D. Line, “Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis,” Endoscopy, vol. 39, no. 12, pp. 1068–1071, 2007.
- K. Mönkemüller, M. Bellutti, H. Neumann, and P. Malfertheiner, “Therapeutic ERCP with the double-balloon enteroscope in patients with Roux-en-Y anastomosis,” Gastrointestinal Endoscopy, vol. 67, no. 6, pp. 992–996, 2008.
- C. Maaser, F. Lenze, M. Bokemeyer et al., “Double balloon enteroscopy: a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system,” American Journal of Gastroenterology, vol. 103, no. 4, pp. 894–900, 2008.
- Y.-C. Chu, C.-C. Yang, Y.-H. Yeh, C.-H. Chen, and S.-K. Yueh, “Double-balloon enteroscopy application in biliary tract disease-its therapeutic and diagnostic functions,” Gastrointestinal Endoscopy, vol. 68, no. 3, pp. 585–591, 2008.
- K. Mönkemüller, L. C. Fry, M. Bellutti, H. Neumann, and P. Malfertheiner, “ERCP using single-balloon instead of double-balloon enteroscopy in patients with Roux-en-Y anastomosis,” Endoscopy, vol. 40, supplement 2, pp. E19–E20, 2008.
- T. Itoi, K. Ishii, A. Sofuni et al., “Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video),” American Journal of Gastroenterology, vol. 105, no. 1, pp. 93–99, 2010.
- G. Ersoz, O. Tekesin, and A. O. Ozutemiz, “Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract,” Gastrointestinal Endoscopy, vol. 57, pp. 156–159, 2003.
- A. Maydeo and S. Bhandari, “Balloon sphincteroplasty for removing difficult bile duct stones,” Endoscopy, vol. 39, no. 11, pp. 958–961, 2007.
- A. Minami, S. Hirose, T. Nomoto, and S. Hayakawa, “Small sphincterotomy combined with papillary dilation with large balloon permits retrieval of large stones without mechanical lithotripsy,” World Journal of Gastroenterology, vol. 13, no. 15, pp. 2179–2182, 2007.
- J. H. Heo, D. H. Kang, H. J. Jung et al., “Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones,” Gastrointestinal Endoscopy, vol. 66, no. 4, pp. 720–726, 2007.
- S. Attasaranya, Y. K. Cheon, H. Vittal et al., “Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series,” Gastrointestinal Endoscopy, vol. 67, no. 7, pp. 1046–1052, 2008.
- T. Itoi, F. Itokawa, A. Sofuni et al., “Endoscopic sphincterotomy combined with large balloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones,” American Journal of Gastroenterology, vol. 104, no. 3, pp. 560–565, 2009.
- S. Jeong, S.-H. Ki, D. H. Lee et al., “Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: a preliminary study,” Gastrointestinal Endoscopy, vol. 70, no. 5, pp. 915–922, 2009.
- A. Larghi and I. Waxman, “Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study,” Gastrointestinal Endoscopy, vol. 63, no. 6, pp. 853–857, 2006.
- J. H. Moon, B. M. Ko, H. J. Choi et al., “Intraductal balloon-guided direct peroral cholangioscopy with an ultraslim upper endoscope (with videos),” Gastrointestinal Endoscopy, vol. 70, no. 2, pp. 297–302, 2009.
Copyright © 2009 Takao Itoi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.