St Luke's, Emory, & Mayo can - ERCP in Roux-en-Y

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Abstract Title: ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) SUCCESS RATES

FOLLOWING ROUX-EN-Y SURGERY

Author(s): MJ

Levy, S

Goldschmid, MJ

Wiersema, KN

Lim, S

Soroka, JE

Geenen, MF

Catalano

St Luke’s Medical Center, Milwaukee, WI; Emory

University, Atlanta, GA; The Mayo Clinic, Rochester MN, USA

Abstract:

Background: Performing

an ERCP on patients with prior history of a Roux-en-Y surgery is often

technically challenging. We describe our experience

with ERCP in this patient population.

Methods

We retrospectively reviewed the charts of 24 patients,

13 males and 11 females, mean age 65 years (range 42-79 years), who previously

underwent a Roux-en-Y surgery and were referred for ERCP. The

indications included suspected

choledocholithiasis (n=13),

obstructive jaundice (n=5), cholangitis (n=3),

acute pancreatitis (n=2)

or a pancreatic mass (n=1).

Results

Cannulation of the desired duct, or ducts, was possible in 13 of

the 24 patients (54%). Cannulation

was achieved with a diagnostic duodenoscope (eight of

13), or pediatric colonoscope (five of 13). In the 13 patients in whom cannulation

was achieved, ERCP established the diagnosis of choledocholithiasis

in 10 (77%), a stricture in two (15%), and sphincter of Oddi

dysfunction (SOD) in one patient (8%). Therapeutic

intervention was successfully performed in 9 of 10 (90%) with choledocholithiasis, in two of two (100%) with a stricture

and in one of one patient with SOD (100%).

Diagnosis

Frequency of

diagnosis

Therapy

successful

Bile duct stone

10/13 (77%)

9/10 (90%)

Stricture

2/13 (15%)

2/2 (100%)

SOD

1/13 (8%)

1/1 (100%)

Patients with bile duct stones underwent an endoscopic sphincterotomy and

stone extraction. Bile duct stone clearance was

incomplete in one patient necessitating initial stent placement and follow-up

ERCP. Stents were inserted in the two patients with

strictures. Inability to locate the papilla accounted

for most of the failed cannulations.

All patients with obstructive jaundice or cholangitis

(n=7) who had unsuccessful ERCP

underwent subsequent successful percutaneous transhepatic biliary drainage. One

patient experienced intestinal perforation and required surgical intervention. Mild pancreatitis developed in

two patients.

Conclusions

Performing an ERCP in patients with a prior Roux-en-Y

surgery is often technically demanding and is associated with a higher failure

rate then typically seen with normal anatomy. However,

a diagnosis can often be safely established and successful therapeutic

intervention is usually possible in those patients in whom cannulation

is achieved. Use of both duodenoscopes

and pediatric colonoscopes may increase diagnostic

and therapeutic success.

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