A new method to identify the afferent limb in balloon enteroscopy-assisted ERCP: Retention of gel mixed with contrast medium under fluoroscopy

In recent years, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BA-ERCP) has been performed for biliary pancreatic endoscopic procedures for postoperative reconstruction of the intestinal tract. In BA-ERCP, especially in cases after Roux-en-Y anastomosis, it is often difficult to identify the afferent limb. Several methods have been reported so far [1] [2] [3]. Herein we report a new method that can discriminate more objectively.

We present a video of a typical case ([Video 1]). The patient was an 83-year-old man who had undergone total gastrectomy and Roux-en-Y anastomosis for gastric cancer ([Fig. 1]). Because of treatment for obstructive jaundice, he was transferred to our hospital and underwent BA-ERCP. The initial procedure, which took 2 hours, could not be completed as it was difficult to identify the afferent limb. BA-ERCP was attempted 4 days later. After crossing the anastomotic site ([Fig. 2]), a mixture of gel (VISCOCLEAR; Otsuka Pharmaceutical Factory, Tokushima, Japan) mixed with contrast medium was slowly sprayed. Outflow of mixed fluid reflecting forward peristalsis was confirmed, and it was judged to be an efferent limb ([Fig. 3]). Next, the endoscope was advanced into the other lumen and the mixed solution was sprayed in the same manner. Retention of the mixed solution reflecting reverse peristalsis was confirmed, therefore this lumen was considered an afferent limb ([Fig. 4]). After this, we were able to reach the duodenal papilla and complete endoscopic bile duct drainage ([Fig. 5]). It took 35 minutes to reach the duodenal papilla.

Video 1 A case in which “retention of gel mixed with contrast medium under fluoroscopy” was useful as a new method to determine the afferent limb in balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography.

Fig. 1 Computed tomography on admission showed bile duct dilatation and reconstructed bowel after gastric surgery.

Fig. 2 When reaching the anastomotic site, it was difficult to decide in which direction to proceed.

Fig. 3 Fluoroscopic image in an efferent limb. A mixture of VISOCLEAR gel mixed with contrast medium was slowly sprayed and outflow of mixed fluid reflecting forward peristalsis was confirmed (yellow arrow).

Fig. 4 Fluoroscopic image in an afferent limb. Retention of the mixed solution reflecting reverse peristalsis was confirmed.

Fig. 5 We were able to reach the duodenal papilla and complete endoscopic bile duct drainage.

The use of gel in gastrointestinal endoscopy has been reported as a means to secure the visual field for endoscopic hemostasis (gel immersion method [4]). The identification of the afferent limb in the postoperative reconstructed bowel that we reported is a new method of using gel. This simple and inexpensive method is thought to greatly contribute to finding the papilla during BA-ERCP in patients with postoperative reconstruction of the intestinal tract.

Endoscopy_UCTN_Code_CCL_1AZ_2AK

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Yano T, Hatanaka H, Yamamoto H. et al. Intraluminal injection of indigo carmine facilitates identification of the afferent limb during double-balloon ERCP. Endoscopy 2012; 44: E340-E341
• 2 Fukuba N, Moriyama I, Ishihara S. et al. Carbon dioxide enterography: a useful method for double-balloon enteroscopy-assisted ERCP. Endoscopy 2014; 46: E587-E588
• 3 Iwasaki T, Akasaka T, Sakakibara Y. et al. Identification of retrograde peristalsis determines the afferent limb during double-balloon ERCP: the tidal wave sign. Endoscopy 2019; 51: E141-E142
• 4 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811

Publication History

Article published online:
02 December 2022