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Endoscopic Retrograde Cholangiopancreatography Using a Double Balloon Endoscope in Roux-En-Y Surgical Bypass Patients: A Case Series
Abstracts
M1353 New Endoscopic Technique for Multiple Plastic Stent Placements in the Common Bile Duct (CBD) Without the Need for Recannulation, Utilizing a Special Loop Tip Wire Guide (LTWG) and a New Loop On Loop Technique (LOL) Juan C. Ayala, Ricardo Labbe, Marcelo Moran, Emilio Vera Currently, there are several endoscopic techniques that allow for multiple plastic stent placements in the CBD without having to regain ductal access through the stricture, which can involve the use of at least one 480 cm. wire guide. When using this technique, difficulties occur when there is a need to place more than two stents through the narrow space of the stricture that is presently occupied by the wire guide and the prostheses. This can lead to the failure of the procedure. Objective: The Loop Tip Wire Guide (Cook Company) is a new wire guide with a loop at the distal flexible end of the device that allows for the passage through strictures, irregular surfaces, and avoids the formation of false tracks. The loop configuration allows for the wire guide to be backloaded onto pre-positioned wire guides with the same characteristics, without having to use a catheter to cannulate the papilla and struggle to pass narrow strictures, thus assuring the success of the procedure leading to reduced anesthesia and fluoroscopy time. Method: The Loop Tip Wire Guide (LTWG) maneuver consists of gaining access to the desired ductal location and performing a wire guide exchange. The loop tip of a second wire guide, which can be either long or short, is backloaded onto the first wire guide then continuing to advance the LTWG through the accessory channel using a monorail technique, so that the second LTWG follows the same route as the first LTWG passing through the stricture until reaching the end of the first LTWG. Once the second LTWG has passed the end of the first LTWG, the two wire guides disengage; this is referred to as the Loop on Loop (LOL) technique. Utilizing the LOL technique for the second LTWG does not require the use of a catheter. The steps can be repeated when placing additional LTWG’s to accommodate the number of stents the patient requires. Once the LTWG’s are in position, stents can be placed in the traditional fashion. All procedures performed are recorded on video. Results: Twelve patients received an ERCP for CBD strictures related to gallbladder cancer invasion of the CBD. Ductal access was achieved through the stricture, a wire guide exchange performed and the LOL technique was used to place an additional two to three LTWG’s. The stents were placed without difficulty using the LOL technique. The LOL technique provides assurance for security and efficiency with successful procedural outcomes. Conclusions: The LOL technique with the LTWG is a new alternative for the placement of multiple plastics stents in the CBD that assures the success of the procedure, diminishes the operative time and avoids the complications of the false tracks.
M1355 Endoscopic Retrograde Cholangiopancreatography Using a Double Balloon Endoscope in Roux-En-Y Surgical Bypass Patients: A Case Series Daniel S. Emmett, Damien Mallat Introduction: The altered gastrointestinal tract anatomy created by Roux-en-Y surgical procedures presents a technical challenge when diagnostic and/or therapeutic endoscopic procedures are required. Until recently, endoscopic retrograde cholangiopancreatography (ERCP) was nearly impossible in patients that are status post (s/p) Roux-en-Y surgery. The recent introduction of the doubleballoon endoscope permits the examination of a much longer segment of the small bowel as compared with a standard endoscope. We present our initial doubleballoon/ERCP experience in patients who are s/p Roux-en-Y surgical procedures. Methods: Between October 10, 2005 and October 25, 2006, 13 patients with a history of either Roux-en-Y gastric bypass weight reduction surgery or Roux-en-Y pancreatobiliary surgery required diagnostic and/or therapeutic pancreatobiliary intervention. Six were status-post weight reduction surgery, two were s/p duodenal sparing Roux-en-Y Whipple, one was s/p Roux-en-Y pancreaticojejunostomy, one was s/p Frey procedure, two were s/p orthotopic liver transplantation with Roux-enY choledocojejunostomy, and one was thought to have had a Roux-en-Y but was found to have a Billroth II at the time of procedure. Written informed consent was obtained from all patients. ERCP was performed using the Fujinon double-balloon endoscopy system. Accessories made by Cook Endoscopy were used to accommodate the longer length of the scope. General anesthesia was used in all cases. Results: These 13 patients underwent a total of 17 ERCPs using the doubleballoon endoscopy system. The ampulla was reached successfully in 82% of total cases (100% of weight reduction patients), with adequate cannulation of either the biliary or pancreatic duct in 76% (88% of weight reduction patients). Therapeutic intervention including stone removal, pancreatobiliary duct dilation, sphincterotomy, and removal of previously placed stents, was performed successfully in 5 patients. In three procedures the region of the ampulla was not reached: 1 due to copious amounts of food forcing abortion of the study, 1 due to scope malfunction, and 1 due to difficulty related to post-surgical adhesions. Two of these three patients returned for repeat procedures, which were both successful. The mean age of the patients was 46. The mean total duration of the procedure was 101 minutes. There were no immediate or short-term complications. Conclusions: The double-balloon endoscopy system permits diagnostic and therapeutic ERCP in patients who have had long-limb surgical procedures. Our experience demonstrates that this procedure is well tolerated, safe, and has a high success rate.
M1356 Prone Or Supine Position When Performing ERCP? Results of a Prospective Randomized Trial Andrea Tringali, Massimiliano Mutignani, Angelo Milano, Pietro Familiari, Federico Iacopini, Cristiano Spada, Michele Marchese, Lucio Petruzziello, Guido Costamagna M1354 The Loop Tip Wire Guide: A New Device to Facilitate Better Access Through the Papilla Juan C. Ayala, Ricardo Labbe, Emilio Vera, Marcelo Moran Background: Most complications in ERCP result from a difficult cannulation, which is influenced by factors including the operator, the ERCP team, the accessories used, and anatomical characteristics of the papilla, such as its location, internal valves, ductal axes, length of the papilla and periampular muscles groups. Anatomical studies of the major papila carried out in our hospital led to a new wire guide design that would permit access to the CBD surely, effectively and easily. Objectives: To develop a device that allows easy access through the papilla toward the desired duct in a sure and effective way with lower complication rates compared to those published rates associated with current devices and techniques. A 0.035 Loop Tip Wire Guide (LTWG) is presented that has at its flexible, distal end a closed loop designed to help avoid catching on the papillary fronds, while at the same time allowing the wire guide to adapt quickly to the changes in internal axes and angles of the ductal system. Design: With the support of Cook Endoscopy, a 0.035 wire guide was designed with a closed loop at its flexible, distal tip, while otherwise maintaining the characteristics of the current Metro Direct wire guide (Cook Endoscopy). The bigger size of the tip, due to the loop, was designed with the objective of avoiding catching on the internal fronds of the papilla or creating false channels. Methods: Between 11-1-2004 and 11-30-2006, we performed 781 ERCPs, of which 300 were carried out with the LTWG in a similar way by 4 doctors, using the LTWG as the primary method to gain access to the CBD. Results: It was possible to gain access to the desired duct in 294 cases (98%) with the LTWG. We failed to gain access to the CBD with the LTWG in 6 cases: precut due to impacted stones (4), benign fibrosis of the papilla due to previous precut (1) and papilla in third portion of the duodenum (1). There were no perforations, false channels, or bleeding due to the use of the LTWG. An operator with less than 50 ERCPs achieved a success rate of 95% in gaining access to the CBD. There were no cases of pancreatitis attributable to the LTWG. Conclusions: The LTWG is a new device with a unique tip that permits safe wire guide cannulation. It facilitates access through the papilla and it could diminish the complications created by young doctors during their learning curve.
AB236 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed in the prone or left lateral position. The supine position could be more comfortable and may facilitate airway management. Recently Terruzzi et al. (Endoscopy, Dec 2005) showed more technical difficulties and a greater risk of adverse cardiorespiratory events performing ERCP in the supine decubitus. Our aim was to assess the differences in terms of technical features and complication, during and after the procedures, when performing ERCP in the supine or prone position. Patients and Methods: Between December 2005 and May 2006, 120 patients 66 F, mean age 62 years) with an intact papilla and candidate to therapeutic ERCP were prospectively randomized to perform ERCP in the prone (n Z 60) or supine (n Z 60) position by an expert endoscopist (tutor) or a trainee (! 1 sphincterotomy/ week). The following parameters were recorded: time needed to visualize the papilla and to achieve deep cannulation, total exam duration, n of main pancreatic duct (MPD) opacifications, cannulation difficulty (Freeman score), ERCP difficulty (Shutz score), episodes of brady/tachy -cardia, desaturation and complications. All the procedures were performed under conscious sedation with midazolam. Results: 98 patients underwent ERCP for benign disease (bile duct stones, benign stricture, leak) and 22 for malignant biliary strictures. Results are summarized in the table. Conclusions: ERCP in the supine position is equally effective and safe than in the prone position both when performed by tutors and trainees. Tutor
Trainee
Prone Supine P Prone Supine P Mean time to visualize the papilla (min:sec) 00:57 Mean time to deep cannulation (min:sec) 5:46 Mean n of MPD opacification 0.73 Exam duration (min:sec) 23:10 Mean cannulation difficulty (Freeman) 2.1 Mean ERCP difficulty (Schutz) 3.73 Episodes of brady/tachycardia (n ) 1 Episodes of desaturation (n ) 2 Complications (n) 0 )Severe acute pancreatitis not requiring surgery.
00:40 4:22 0.70 23:00 2.1 3.52 1 2 1
n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
2:19 5:46 1.43 27:58 4.23 3.50 8 4 1)
1:46 5:48 2.03 25:00 3.86 3.20 6 5 0
n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
www.giejournal.org
M1353 New Endoscopic Technique for Multiple Plastic Stent Placements in the Common Bile Duct (CBD) Without the Need for Recannulation, Utilizing a Special Loop Tip Wire Guide (LTWG) and a New Loop On Loop Technique (LOL) Juan C. Ayala, Ricardo Labbe, Marcelo Moran, Emilio Vera Currently, there are several endoscopic techniques that allow for multiple plastic stent placements in the CBD without having to regain ductal access through the stricture, which can involve the use of at least one 480 cm. wire guide. When using this technique, difficulties occur when there is a need to place more than two stents through the narrow space of the stricture that is presently occupied by the wire guide and the prostheses. This can lead to the failure of the procedure. Objective: The Loop Tip Wire Guide (Cook Company) is a new wire guide with a loop at the distal flexible end of the device that allows for the passage through strictures, irregular surfaces, and avoids the formation of false tracks. The loop configuration allows for the wire guide to be backloaded onto pre-positioned wire guides with the same characteristics, without having to use a catheter to cannulate the papilla and struggle to pass narrow strictures, thus assuring the success of the procedure leading to reduced anesthesia and fluoroscopy time. Method: The Loop Tip Wire Guide (LTWG) maneuver consists of gaining access to the desired ductal location and performing a wire guide exchange. The loop tip of a second wire guide, which can be either long or short, is backloaded onto the first wire guide then continuing to advance the LTWG through the accessory channel using a monorail technique, so that the second LTWG follows the same route as the first LTWG passing through the stricture until reaching the end of the first LTWG. Once the second LTWG has passed the end of the first LTWG, the two wire guides disengage; this is referred to as the Loop on Loop (LOL) technique. Utilizing the LOL technique for the second LTWG does not require the use of a catheter. The steps can be repeated when placing additional LTWG’s to accommodate the number of stents the patient requires. Once the LTWG’s are in position, stents can be placed in the traditional fashion. All procedures performed are recorded on video. Results: Twelve patients received an ERCP for CBD strictures related to gallbladder cancer invasion of the CBD. Ductal access was achieved through the stricture, a wire guide exchange performed and the LOL technique was used to place an additional two to three LTWG’s. The stents were placed without difficulty using the LOL technique. The LOL technique provides assurance for security and efficiency with successful procedural outcomes. Conclusions: The LOL technique with the LTWG is a new alternative for the placement of multiple plastics stents in the CBD that assures the success of the procedure, diminishes the operative time and avoids the complications of the false tracks.
M1355 Endoscopic Retrograde Cholangiopancreatography Using a Double Balloon Endoscope in Roux-En-Y Surgical Bypass Patients: A Case Series Daniel S. Emmett, Damien Mallat Introduction: The altered gastrointestinal tract anatomy created by Roux-en-Y surgical procedures presents a technical challenge when diagnostic and/or therapeutic endoscopic procedures are required. Until recently, endoscopic retrograde cholangiopancreatography (ERCP) was nearly impossible in patients that are status post (s/p) Roux-en-Y surgery. The recent introduction of the doubleballoon endoscope permits the examination of a much longer segment of the small bowel as compared with a standard endoscope. We present our initial doubleballoon/ERCP experience in patients who are s/p Roux-en-Y surgical procedures. Methods: Between October 10, 2005 and October 25, 2006, 13 patients with a history of either Roux-en-Y gastric bypass weight reduction surgery or Roux-en-Y pancreatobiliary surgery required diagnostic and/or therapeutic pancreatobiliary intervention. Six were status-post weight reduction surgery, two were s/p duodenal sparing Roux-en-Y Whipple, one was s/p Roux-en-Y pancreaticojejunostomy, one was s/p Frey procedure, two were s/p orthotopic liver transplantation with Roux-enY choledocojejunostomy, and one was thought to have had a Roux-en-Y but was found to have a Billroth II at the time of procedure. Written informed consent was obtained from all patients. ERCP was performed using the Fujinon double-balloon endoscopy system. Accessories made by Cook Endoscopy were used to accommodate the longer length of the scope. General anesthesia was used in all cases. Results: These 13 patients underwent a total of 17 ERCPs using the doubleballoon endoscopy system. The ampulla was reached successfully in 82% of total cases (100% of weight reduction patients), with adequate cannulation of either the biliary or pancreatic duct in 76% (88% of weight reduction patients). Therapeutic intervention including stone removal, pancreatobiliary duct dilation, sphincterotomy, and removal of previously placed stents, was performed successfully in 5 patients. In three procedures the region of the ampulla was not reached: 1 due to copious amounts of food forcing abortion of the study, 1 due to scope malfunction, and 1 due to difficulty related to post-surgical adhesions. Two of these three patients returned for repeat procedures, which were both successful. The mean age of the patients was 46. The mean total duration of the procedure was 101 minutes. There were no immediate or short-term complications. Conclusions: The double-balloon endoscopy system permits diagnostic and therapeutic ERCP in patients who have had long-limb surgical procedures. Our experience demonstrates that this procedure is well tolerated, safe, and has a high success rate.
M1356 Prone Or Supine Position When Performing ERCP? Results of a Prospective Randomized Trial Andrea Tringali, Massimiliano Mutignani, Angelo Milano, Pietro Familiari, Federico Iacopini, Cristiano Spada, Michele Marchese, Lucio Petruzziello, Guido Costamagna M1354 The Loop Tip Wire Guide: A New Device to Facilitate Better Access Through the Papilla Juan C. Ayala, Ricardo Labbe, Emilio Vera, Marcelo Moran Background: Most complications in ERCP result from a difficult cannulation, which is influenced by factors including the operator, the ERCP team, the accessories used, and anatomical characteristics of the papilla, such as its location, internal valves, ductal axes, length of the papilla and periampular muscles groups. Anatomical studies of the major papila carried out in our hospital led to a new wire guide design that would permit access to the CBD surely, effectively and easily. Objectives: To develop a device that allows easy access through the papilla toward the desired duct in a sure and effective way with lower complication rates compared to those published rates associated with current devices and techniques. A 0.035 Loop Tip Wire Guide (LTWG) is presented that has at its flexible, distal end a closed loop designed to help avoid catching on the papillary fronds, while at the same time allowing the wire guide to adapt quickly to the changes in internal axes and angles of the ductal system. Design: With the support of Cook Endoscopy, a 0.035 wire guide was designed with a closed loop at its flexible, distal tip, while otherwise maintaining the characteristics of the current Metro Direct wire guide (Cook Endoscopy). The bigger size of the tip, due to the loop, was designed with the objective of avoiding catching on the internal fronds of the papilla or creating false channels. Methods: Between 11-1-2004 and 11-30-2006, we performed 781 ERCPs, of which 300 were carried out with the LTWG in a similar way by 4 doctors, using the LTWG as the primary method to gain access to the CBD. Results: It was possible to gain access to the desired duct in 294 cases (98%) with the LTWG. We failed to gain access to the CBD with the LTWG in 6 cases: precut due to impacted stones (4), benign fibrosis of the papilla due to previous precut (1) and papilla in third portion of the duodenum (1). There were no perforations, false channels, or bleeding due to the use of the LTWG. An operator with less than 50 ERCPs achieved a success rate of 95% in gaining access to the CBD. There were no cases of pancreatitis attributable to the LTWG. Conclusions: The LTWG is a new device with a unique tip that permits safe wire guide cannulation. It facilitates access through the papilla and it could diminish the complications created by young doctors during their learning curve.
AB236 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed in the prone or left lateral position. The supine position could be more comfortable and may facilitate airway management. Recently Terruzzi et al. (Endoscopy, Dec 2005) showed more technical difficulties and a greater risk of adverse cardiorespiratory events performing ERCP in the supine decubitus. Our aim was to assess the differences in terms of technical features and complication, during and after the procedures, when performing ERCP in the supine or prone position. Patients and Methods: Between December 2005 and May 2006, 120 patients 66 F, mean age 62 years) with an intact papilla and candidate to therapeutic ERCP were prospectively randomized to perform ERCP in the prone (n Z 60) or supine (n Z 60) position by an expert endoscopist (tutor) or a trainee (! 1 sphincterotomy/ week). The following parameters were recorded: time needed to visualize the papilla and to achieve deep cannulation, total exam duration, n of main pancreatic duct (MPD) opacifications, cannulation difficulty (Freeman score), ERCP difficulty (Shutz score), episodes of brady/tachy -cardia, desaturation and complications. All the procedures were performed under conscious sedation with midazolam. Results: 98 patients underwent ERCP for benign disease (bile duct stones, benign stricture, leak) and 22 for malignant biliary strictures. Results are summarized in the table. Conclusions: ERCP in the supine position is equally effective and safe than in the prone position both when performed by tutors and trainees. Tutor
Trainee
Prone Supine P Prone Supine P Mean time to visualize the papilla (min:sec) 00:57 Mean time to deep cannulation (min:sec) 5:46 Mean n of MPD opacification 0.73 Exam duration (min:sec) 23:10 Mean cannulation difficulty (Freeman) 2.1 Mean ERCP difficulty (Schutz) 3.73 Episodes of brady/tachycardia (n ) 1 Episodes of desaturation (n ) 2 Complications (n) 0 )Severe acute pancreatitis not requiring surgery.
00:40 4:22 0.70 23:00 2.1 3.52 1 2 1
n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
2:19 5:46 1.43 27:58 4.23 3.50 8 4 1)
1:46 5:48 2.03 25:00 3.86 3.20 6 5 0
n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
www.giejournal.org