ERCP in patients with Roux-en-Y anatomy

INTRODUCTION — Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy poses a major challenge to gastrointestinal endoscopists. In the era of the obesity epidemic, this situation is encountered with increasing frequency due to the popularity of Roux-en-Y gastric bypass (RYGB) surgery (figure 1) and the high prevalence of gallstone disease in these patients [1-3]. (See "Bariatric procedures for the management of severe obesity: Descriptions", section on 'Roux-en-Y gastric bypass'.)

Roux-en-Y anatomy may also result from:

●Gastric resection surgery (figure 2 and figure 3). (See "Partial gastrectomy and gastrointestinal reconstruction" and "Total gastrectomy and gastrointestinal reconstruction".)

●Pancreaticoduodenectomy (figure 4 and figure 5 and figure 6). (See "Surgical resection of lesions of the head of the pancreas" and "Surgical resection of lesions of the body and tail of the pancreas".)

●Liver transplantation. (See "Living donor liver transplantation in adults".)

●Other biliary tract surgeries, such as the repair of bile duct injuries or as part of the treatment of cholangiocarcinoma, resulting in the formation of a hepaticojejunostomy (figure 7) or choledochojejunostomy. (See "Repair of common bile duct injuries", section on 'Repair options' and "Adjuvant and neoadjuvant therapy for localized cholangiocarcinoma", section on 'Overview of surgical treatment and prognosis'.)

In patients with Roux-en-Y anatomy, it is frequently impossible to access the papilla (or bilioenteric/pancreatoenteric anastomosis) using a standard duodenoscope due to the length and the angulation of bowel that must be traversed. For example, in the case of RYGB, an endoscope advanced through the "anatomic route" must traverse the esophagus, gastric pouch, and Roux limb (typically 100 to 150 cm in length), and then navigate the acute angle at the jejunojejunostomy into the biliopancreatic limb up to the papilla (an additional 80 to 100 cm). Moreover, in cases with a native papilla, the endoscopist is then faced with the challenge of cannulating the bile duct or pancreatic duct while approaching the papilla from a reverse position. (See "Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction", section on 'Cannulating the papilla from the reverse position'.)

To overcome these problems, non-standard approaches, innovative techniques including endoscopic ultrasound (EUS)-directed technique, and specialized accessories have been developed to perform ERCP in patients with Roux-en-Y anatomy. Where available, percutaneous transhepatic cholangioscopy may be an option for patients in whom ERCP cannot be successfully performed. (See "Percutaneous transhepatic cholangioscopy".)

This topic will review the different approaches to performing ERCP in patients with Roux-en-Y anatomy. An overview of endoscopy in patients who have undergone bariatric surgery, an overview of ERCP, the approach to ERCP in patients who have undergone a Billroth II reconstruction, and percutaneous transhepatic cholangioscopy are discussed separately.

●(See "Gastrointestinal endoscopy in patients who have undergone bariatric surgery".)

●(See "Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction".)

●(See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

●(See "Percutaneous transhepatic cholangioscopy".)

GENERAL CONSIDERATIONS — Prior to attempting endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy, the endoscopist should review the operative note or, ideally, discuss the expected anatomy with the surgeon. Specifically, the endoscopist should obtain details about the anatomic resection, the type of reconstruction, the length of the limbs, the types of anastomoses (eg, end-to-side versus side-to-side), and the presence or absence of a native papilla. In addition, all relevant postoperative imaging studies should be reviewed, especially magnetic resonance cholangiopancreatography (MRCP) studies, if available.

As a final consideration, it is important to be aware of the time interval following surgery. In the early postoperative period, it is important to weigh the risks of instrumentation with regards to anastomotic disruption against the potential benefits of ERCP.

Choosing the best approach — There are several techniques available to perform ERCP in patients with Roux-en-Y anatomy, each with advantages and disadvantages (figure 8 and table 1) [4]. No single approach has been identified as the best for all patients, so the endoscopist must select the approach on a case-by-case basis, taking the following factors into consideration:

●Roux limb length (long versus short)

●Whether the patient has a native papilla or a bilio/pancreato-enteric anastomosis

●The indication for ERCP, including the likelihood of repeat procedures and the need for therapeutic maneuvers

●The availability of local expertise (deep enteroscopy, interventional radiology, surgery)

●The patient's surgical risk

Native papilla — In patients with a native papilla, the endoscopist should select a technique that allows for the use of a duodenoscope. A duodenoscope is greatly preferred because it increases the chance of successful selective cannulation of the bile and/or pancreatic duct in patients with a native papilla. Transoral advancement of a duodenoscope through the anatomic route can be attempted in patients with a short Roux limb, although this approach is arduous and frequently unsuccessful. (See 'ERCP using standard duodenoscope' below.)

For patients with a long Roux limb and a native papilla, the best option is often ERCP through a gastrostomy or jejunostomy or a laparoscopy-assisted ERCP. If repeated ERCPs are anticipated, access via a gastrostomy tube placed in the excluded stomach is recommended. The gastrostomy tube can be placed percutaneously by interventional radiology in patients who are poor surgical candidates. (See 'Surgical approaches' below.)

An alternative approach commonly utilized for patients with gastric bypass involves the creation of a gastrogastric fistula via endoscopic ultrasound-guided placement of a lumen-apposing metal stent into the bypassed stomach [5]. A duodenoscope can then be passed through the metal stent to perform ERCP.

Bilioenteric or pancreatoenteric anastomosis — In patients with bilioenteric and pancreatoenteric anastomoses, forward-viewing endoscopes are adequate for performing ERCP. Enteroscopes or colonoscopes can be used for patients with a short Roux limb, whereas deep enteroscopy techniques such as balloon-assisted enteroscopy or spiral enteroscopy are preferable in patients with a long Roux limb. (See 'ERCP using an enteroscope or pediatric colonoscope' below and 'ERCP using deep enteroscopy techniques' below.)

TRANSORAL APPROACHES — Transoral approaches entail the use of duodenoscopes, pediatric colonoscopes, or enteroscopes advanced per os through the anatomic route.

ERCP using standard duodenoscope — The side-viewing duodenoscope is the ideal endoscope to perform ERCP, particularly for the cannulation of a native papilla. Unfortunately, the duodenoscope-only approach is frequently unsuccessful, as shown in one small series in which ERCP was successfully performed in only 33 percent of Roux-en-Y patients [6]. Therefore, we reserve the transoral approach using a standard duodenoscope for patients with a short Roux limb.

ERCP using an enteroscope or pediatric colonoscope — An enteroscope or pediatric colonoscope may be an option for performing an ERCP when using a duodenoscope is not feasible. In one series, 18 patients with Roux-en-Y anatomy (including three Roux-en-Y gastric bypass patients) underwent a total of 25 attempted ERCPs using a pediatric colonoscope (164 cm working length) and/or enteroscope (240 cm working length) [7]. Successful advancement of the endoscope to the level of the papilla or the bilioenteric/pancreatoenteric anastomosis was accomplished in 84 percent of attempted procedures. Biliary cannulation was successful in 94 percent (including five of six procedures performed on patients with intact papillae), and endoscopic treatment was performed in 86 percent.

A disadvantage of this approach is that the forward-viewing perspective and the lack of an instrument elevator make selective duct cannulation more difficult when addressing an intact papilla. In addition, the maneuverability of the long enteroscope or colonoscope can be very limited due to torsion of the scope shaft and loop formation. Finally, deflection of the scope tip can make the introduction of accessories through the working channel difficult or impossible. To overcome these problems, forward-viewing endoscopes can be used initially to navigate the anatomic route. Once the papilla is reached, a guidewire is placed, over which a duodenoscope is subsequently advanced.

One study described the use of this technique in a series of 15 patients with long-limb Roux-en-Y anatomy and an intact papilla, 11 of whom had undergone Roux-en-Y gastric bypass (RYGB) surgery [8]. On several occasions, a large diameter ERCP stone-extraction balloon was advanced over the wire and inflated in the biliopancreatic limb or bypassed stomach, serving as an anchor as the duodenoscope was passed over the catheter into the region of the papilla. Other maneuvers similar to those used during colonoscopy (straightening loops, changing patient position, and applying manual abdominal pressure) were performed to facilitate duodenoscope advancement. ERCP was ultimately successful in 10 of the 15 patients (67 percent), with the main reason for failure being the inability to pass an endoscope to the region of the papilla. Of note, the five patients in whom ERCP was not possible had all undergone RYGB, underscoring the need for alternative methods to perform successful ERCP in this important patient population.

ERCP using deep enteroscopy techniques — There is significant experience with the performance of ERCP using deep enteroscopy techniques, including double-balloon enteroscopy (DBE) (picture 1 and figure 9), single-balloon enteroscopy (SBE) (figure 10), and spiral enteroscopy (picture 2). (See "Overview of deep small bowel enteroscopy".)

While deep enteroscopy techniques represent a significant advancement for performing ERCP in patients with surgically altered anatomy, they are not yet widely performed outside of specialized centers. Furthermore, they are fraught with the aforementioned limitations inherent to the use of enteroscopes for ERCP, including restricted maneuverability of the scope (related to looping, adhesions, sharp angulations, and depth of scope insertion), unfavorable orientation of the native papilla, lack of an instrument elevator, and relative paucity of enteroscope-compatible ERCP accessories.

Double balloon enteroscope-assisted ERCP — Based on data largely from case reports and a few case series, the papilla (or bilioenteric/pancreatoenteric anastomosis) can be reached in over 90 percent of cases, and successful selective duct cannulation can be achieved in over 80 percent of cases using the double balloon enteroscope-assisted ERCP (DB-ERCP) technique [9-15].

In one of the first case series describing DB-ERCP in 13 patients with Roux-en-Y anatomy [9], successful bile duct cannulation was achieved in 16 of 18 ERCPs, with therapy being performed in six cases (including stent insertion and removal and stone extraction). Of note, only one of the patients in this series had a native papilla, and ERCP was unsuccessful in this patient due to the inability to approach the papilla at the appropriate angle.

As with other ERCPs using forward-viewing endoscopes, cannulation of the native papilla may be difficult with DB-ERCP. An additional problem when performing DB-ERCP is that there are a limited number of ERCP accessories that are compatible with a standard double balloon enteroscope due to its length. However, this issue can be overcome with the use of a "short" DBE system that has a 152 cm working length and is compatible with conventional accessories [11,16]. One study performed 55 ERCPs in 36 Roux-en-Y total gastrectomy patients using the "short" double balloon enteroscope, achieving successful bile duct cannulation in 50 of 55 procedures (91 percent) [16]. A full spectrum of therapeutic maneuvers were performed, including sphincterotomy, stone extraction, balloon dilation, and the insertion of plastic stents, metal stents, and nasobiliary drainage tubes.

If a "short" double balloon enteroscope is not available, the standard DBE or SBE overtube can be modified to permit the use of a conventional forward-viewing upper endoscope [11,17]. Once the papilla is reached, the enteroscope is removed from the overtube, which is left in place with the balloon inflated to maintain its position near the papilla. Next, a 12 mm aperture is created in the overtube at a point 100 cm from its tip on the side opposite the pressure line (so that the balloon remains inflated). A standard upper endoscope can then be inserted through the aperture and advanced down the overtube into position below the papilla.

Single balloon enteroscope-assisted ERCP — Performance of single balloon enteroscope-assisted ERCP (SB-ERCP) in patients with Roux-en-Y anatomy has been associated with diagnostic success rates ranging from 60 to 80 percent [17-22]. In a meta-analysis of 15 trials with 461 patients, technical, diagnostic, and therapeutic success rates were 81, 69, and 62 percent, respectively [23]. Examples of individual trials include:

●One series that included 50 patients with Roux-en-Y anatomy who underwent a total of 56 SB-ERCPs [19]. Successful diagnostic ERCP was achieved in 39 of 56 procedures (70 percent). Therapeutic ERCP was required in 23 cases, of which 21 were successful (91 percent).

●A second series in which SB-ERCP was compared with ERCP using an adult or pediatric colonoscope in 90 patients with a Roux-en-Y biliary anastomosis [22]. A total of 199 procedures were performed. The rates of successful biliary cannulation were similar for SB-ERCP and ERCP using an adult colonoscope (76 versus 70 percent), whereas SB-ERCP had a higher rate of successful biliary cannulation when compared with ERCP using a pediatric colonoscope (76 versus 59 percent). Similarly, there was no statistically significant difference in the therapeutic success rates between SB-ERCP and ERCP using an adult colonoscope (71 versus 66 percent), but there was a higher success rate for SB-ERCP when it was compared with ERCP using a pediatric colonoscope (71 versus 54 percent).

Spiral enteroscopy-assisted ERCP — Spiral enteroscopy utilizes a rotating overtube (picture 2) that pleats the small bowel onto the overtube and allows deep advancement of an enteroscope. Potential advantages of spiral enteroscopy-assisted ERCP (SE-ERCP) over DB-ERCP or SB-ERCP include relative ease of use, better endoscope control, and perhaps a shorter learning curve [24,25].

Studies of SE-ERCP in a variety of patients with Roux-en-Y anatomy have reported success rates of 55 to 80 percent [24,26-31]. The best available data come from a multi-center study of 129 patients with long-limb surgical bypass anatomy (64 of whom were status-post Roux-en-Y gastric bypass) who underwent a total of 180 ERCPs using DB-ERCP, SB-ERCP, or SE-ERCP [27]. Enteroscopy was successful (ie, there was visualization of the papilla or bilioenteric anastomosis) in 74, 69, and 72 percent, respectively. In patients with enteroscopy success, ERCP was successful in 85, 87, and 90 percent, respectively. Of note, native papilla cannulation was successful in 46 of 73 patients (63 percent). The overall (intention-to-treat) ERCP success rates for the three methods were similar: 63 percent, 60 percent, and 65 percent for DB-ERCP, SB-ERCP, and SE-ERCP, respectively. Complications occurred in 16 of 129 patients (12 percent) and included pancreatitis, perforation, and bleeding.

Other transoral approaches — A technique has been developed that uses EUS-guided placement of a lumen-apposing metal stent (LAMS) between the gastric pouch and the excluded stomach to facilitate a transoral antegrade ERCP using a duodenoscope. Preliminary experience with this approach in patients with Roux-en-Y gastric bypass anatomy has been promising, with similar technical success and adverse event rates compared with laparoscopy assisted-ERCP and enteroscopy-assisted ERCP [32-34]. (See 'Laparoscopy-assisted ERCP' below and 'ERCP using deep enteroscopy techniques' above.)

Preliminary data have also suggested that transoral, transluminal ERCP technique following EUS-guided LAMS placement holds promise for patients with post-surgical anatomy not related to gastric bypass. In a retrospective study including 18 patients with surgically altered anatomy (Roux-en–Y hepaticojejunostomy or pancreaticoduodenostomy in 16 patients [89 percent]), creation of an enteroenteric anastomosis using EUS-guided LAMS placement was successful in all patients, while subsequent ERCP with intervention (eg, stone removal) was successful in 17 patients (94 percent) [35]. One patient had a stricture distal to the enteroenteric anastomosis; thus ERCP could not be completed. Adverse event rate was low with one patient (6 percent) reporting mild abdominal pain that was medically managed. Transluminal ERCP facilitated by EUS-guided LAMS placement may be feasible for patients with Roux-en-Y anatomy if additional studies can validate these results and help define optimal timing for LAMS removal [36].

SURGICAL APPROACHES — When a transoral approach to ERCP is not successful, a surgical approach may be required. The main advantage of a surgical approach in patients with Roux-en-Y anatomy is the ability to perform the procedure using a side-viewing duodenoscope with reliable access and a conventional approach to the papilla. In addition, all standard ERCP accessories can be used.

Surgical approaches include ERCP through a gastrostomy or jejunostomy tract and laparoscopy-assisted ERCP. However, these approaches are more invasive than purely endoscopic approaches and are associated with the risks related to anesthesia and surgery.

Transgastric approach — The transgastric approach appears to be effective and safe in patients with Roux-en-Y anatomy, and variations in the transgastric approach have been described [37-41] (figure 8). The gastrostomy can be placed using a laparoscopic or open surgical approach, or it can be placed percutaneously by interventional radiology. The ERCP can then be performed intraoperatively or after a delay to allow maturation of the tract. The tract can be maintained with a large bore feeding tube if repeated procedures are anticipated.

In a systematic review of 26 studies including 509 Roux-en-Y gastric bypass patients who underwent transgastric ERCP, bile duct cannulation was achieved in 98.5 percent of patients [41]. Gastric access was successfully obtained in all patients by one of the following methods: laparoscopy (58 percent), placement of a percutaneous gastrostomy tube (33 percent), open surgery (6 percent), or endoscopic ultrasound assistance (3 percent). Wound infection was the most common gastrostomy-related adverse event (19 patients, 4 percent), and post-ERCP pancreatitis was the most common ERCP-related adverse event (7 patients, 1 percent).

Laparoscopy-assisted ERCP — Laparoscopy-assisted ERCP (LA-ERCP) involves the laparoscopic creation of an access point into the excluded stomach or small bowel. A duodenoscope is then inserted through a trocar placed into the stomach and advanced to the papilla. This approach requires a great deal of coordination between the surgery and endoscopy teams and is more invasive than purely endoscopic approaches.

One study including 56 patients compared LA-ERCP with balloon enteroscope-assisted ERCP (BEA-ERCP) [42]. LA-ERCP was superior to BEA-ERCP with regard to papilla identification (100 versus 72 percent), cannulation rate (100 versus 59 percent), and therapeutic success (100 versus 59 percent).

Less common approaches — In a case report, ERCP has been successfully performed via a mature jejunostomy tract in a patient with a history of total gastrectomy, esophagogastrectomy, and Roux-en-Y reconstruction [43]. Another approach that has been described entails the use of balloon enteroscopy to access the excluded stomach, performance of a direct retrograde percutaneous endoscopic gastrostomy, followed by deployment of a self-expanding metal sent within the gastrostomy tract. Antegrade ERCP through the stent can then be performed in the same session [44].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endoscopic retrograde cholangiopancreatography (ERCP)".)

SUMMARY AND RECOMMENDATIONS

●Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy is a challenging, frequently arduous task, but there are now several techniques available to endoscopists. There is no single best technique for all patients, so the approach must be selected on a case-by-case basis. (See 'General considerations' above.)

●For patients with a native papilla and a short Roux limb, a transoral approach using a duodenoscope can be attempted, although it is still frequently unsuccessful. (See 'ERCP using standard duodenoscope' above.)

If a transoral approach using a duodenoscope is unsuccessful, a colonoscope or enteroscope may be used to perform the ERCP (recognizing the limitations of forward viewing endoscopes and the relative lack of compatible ERCP accessories) or to initially navigate the anatomic route and facilitate guidewire-assisted duodenoscope insertion into the biliopancreatic limb. (See 'ERCP using an enteroscope or pediatric colonoscope' above.)

●For patients with a native papilla and a long Roux limb (as in most Roux-en-Y gastric bypass patients), deep enteroscopy techniques can be considered. However, ERCP through a gastrostomy or laparoscopy-assisted ERCP are preferable in good surgical candidates. These approaches are preferred because they provide rapid, reliable access to the descending duodenum with visualization of the papilla in the usual orientation for ERCP, and they allow the use of a therapeutic duodenoscope and all standard ERCP accessories. (See 'ERCP using deep enteroscopy techniques' above and 'Surgical approaches' above.)

●For patients without a native papilla (ie, patients with a bilioenteric/pancreatoenteric anastomosis) and a short Roux limb, a forward-viewing endoscope such as a colonoscope or enteroscope can be used in most cases. (See 'ERCP using an enteroscope or pediatric colonoscope' above.)

●For patients without a native papilla and a long Roux limb, deep enteroscopy techniques (double balloon, single balloon, spiral enteroscopy) should be attempted, if available. Alternatively, ERCP through a gastrostomy, EUS-directed transgastric ERCP, or laparoscopy-assisted ERCP can be considered. (See 'ERCP using deep enteroscopy techniques' above.)