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Balloon enteroscopy–assisted ERCP and cholangioscopy
VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Balloon enteroscopy–assisted ERCP and cholangioscopy
Figure 1. Balloon enterosopy–assisted ERCP and cholangioscopy. A, Direct visualization of the common bile duct (CBD) stone. B, The stone is grasped with a polypectomy snare. C, The stone is left in the duodenum. D, Cholangiogram through the operating channel of the enteroscope, showing no residual stones.
ERCP after Roux-en-Y anastomosis is challenging. Balloon enteroscopy–assisted ERCP can be useful, allowing the performance of cholangioscopy and stone extraction (Fig. 1; Video 1, available online at www.giejournal.org). An 80-year-old woman with subtotal Roux-en-Y gastrectomy (RYG) was admitted with abdominal pain lasting for 24 hours. She did not describe having fever or jaundice. Liver blood tests showed elevated alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and g-glutamyltransferase. CT scan and MRCP showed a 1.5-cm stone in the distal part of the common bile duct (CBD). ERCP was attempted with a single-balloon enteroscope (Olympus, Center Valley, Pa) under CO2 www.giejournal.org
insufflation. The endoscope was advanced as far as the major papilla. Cannulation was achieved with use of a CRE balloon because sphincterotomes suited for enteroscopes were not available. Injection of contrast medium confirmed the stone. Sphincteroplasty was performed as far as 15 mm (estimated size of CBD and stone). The enteroscope was advanced into the CBD, allowing direct visualization of the stone. It was removed with a polypectomy snare because baskets or balloons appropriate for enteroscopes were not available. Injection of contrast medium at the end of the procedure did not show residual stones. The patient was discharged free of symptoms. Balloon enteroscopy–assisted ERCP in Volume
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No.
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: 2016 GASTROINTESTINAL ENDOSCOPY 1
VideoGIE
patients with RYG is difficult but feasible. Sphincteroplasty is useful if appropriate sphincterotomes are not available. Cholangioscopy might be performed in selected patients.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
2 GASTROINTESTINAL ENDOSCOPY Volume
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No.
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: 2016
Gustavo Andrade de Paulo, MD, MSc, PhD, Endoscopy Unit, Cancer Institute of São Paulo, Endoscopy Unit, Hospital Albert Einstein, São Paulo, Brazil, Victor Rossi Bastos, MD, Bruno da Costa Martins, MD, PhD, Adriana Vaz Safatle-Ribeiro, MD, PhD, Carla Cristina Gusmon, MD, Marcelo Simas de Lima, MD, Ricardo Sato Uemura, MD, Fauze Maluf Filho, MD, PhD, Endoscopy Unit, Cancer Institute of São Paulo, São Paulo, Brazil http://dx.doi.org/10.1016/j.gie.2016.05.029
www.giejournal.org
Balloon enteroscopy–assisted ERCP and cholangioscopy
Figure 1. Balloon enterosopy–assisted ERCP and cholangioscopy. A, Direct visualization of the common bile duct (CBD) stone. B, The stone is grasped with a polypectomy snare. C, The stone is left in the duodenum. D, Cholangiogram through the operating channel of the enteroscope, showing no residual stones.
ERCP after Roux-en-Y anastomosis is challenging. Balloon enteroscopy–assisted ERCP can be useful, allowing the performance of cholangioscopy and stone extraction (Fig. 1; Video 1, available online at www.giejournal.org). An 80-year-old woman with subtotal Roux-en-Y gastrectomy (RYG) was admitted with abdominal pain lasting for 24 hours. She did not describe having fever or jaundice. Liver blood tests showed elevated alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and g-glutamyltransferase. CT scan and MRCP showed a 1.5-cm stone in the distal part of the common bile duct (CBD). ERCP was attempted with a single-balloon enteroscope (Olympus, Center Valley, Pa) under CO2 www.giejournal.org
insufflation. The endoscope was advanced as far as the major papilla. Cannulation was achieved with use of a CRE balloon because sphincterotomes suited for enteroscopes were not available. Injection of contrast medium confirmed the stone. Sphincteroplasty was performed as far as 15 mm (estimated size of CBD and stone). The enteroscope was advanced into the CBD, allowing direct visualization of the stone. It was removed with a polypectomy snare because baskets or balloons appropriate for enteroscopes were not available. Injection of contrast medium at the end of the procedure did not show residual stones. The patient was discharged free of symptoms. Balloon enteroscopy–assisted ERCP in Volume
-,
No.
-
: 2016 GASTROINTESTINAL ENDOSCOPY 1
VideoGIE
patients with RYG is difficult but feasible. Sphincteroplasty is useful if appropriate sphincterotomes are not available. Cholangioscopy might be performed in selected patients.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2016
Gustavo Andrade de Paulo, MD, MSc, PhD, Endoscopy Unit, Cancer Institute of São Paulo, Endoscopy Unit, Hospital Albert Einstein, São Paulo, Brazil, Victor Rossi Bastos, MD, Bruno da Costa Martins, MD, PhD, Adriana Vaz Safatle-Ribeiro, MD, PhD, Carla Cristina Gusmon, MD, Marcelo Simas de Lima, MD, Ricardo Sato Uemura, MD, Fauze Maluf Filho, MD, PhD, Endoscopy Unit, Cancer Institute of São Paulo, São Paulo, Brazil http://dx.doi.org/10.1016/j.gie.2016.05.029
www.giejournal.org