ERCP after bypass surgery. Which option would patients prefer?

We read with great interest the article by Law et al., in which the authors introduced their experience of performing a modified endoscopic retrograde cholangiopancreatography (ERCP) with the assistance of transprosthetic endoscopic therapy [1]. The balloon enteroscopy was used to access the excluded stomach. A direct retrograde percutaneous endoscopic gastrostoma was created, and then a fully-covered self-expandable metal stent was deployed within the gastrostomy tract. Finally, a regular ERCP was performed through the percutaneous gastrostoma. The results revealed that this method of modified ERCP is feasible and can be performed during a single endoscopic session in patients with previous Roux-en-Y gastric bypass (RYGB).

This procedure involved balloon enteroscopy, creation of the gastrostoma, stent placement, and regular ERCP. Our comment is that there are too many steps involved, which may not all be necessary.

The number of patients undergoing RYGB for weight loss is increasing, and ERCP is more difficult in these patients [2]. In the past 10 years, several studies have performed modified ERCP procedures using single-balloon enteroscopy, double-balloon enteroscopy, and spiral enteroscopy, as well as laparoscopic gastrostomy, with immediate closure after the procedure [3] [4] [5]. Reaching the target papilla, successful cannulation, and postprocedural complications are reported to be similar with each of these three endoscopic methods. The efficiency of pure enteroscopy-assisted ERCP is limited by the length of the limb remaining after surgery, especially after RYGB, and often results in the enteroscope being unable to advance to the papilla.

Despite the limitations, endoscopic therapy is a less invasive and repeatable method. Most patients wish to avoid a gastrostomy if possible. In the report by Choi et al., complications occurred in 14.5 % of the surgical patients; complications in all but one of these patients were associated with the gastrostomy [6]. However, surgery was not appropriate for those patients with urgent conditions, such as severe jaundice and colicky abdominal pain. Furthermore, the cost-effectiveness of procedures is receiving more and more attention: the cost of surgery is usually greater than the endoscopic procedure because an additional procedure is required to create the gastrostomy [6].

Schreiner et al. listed several associated factors that predict the success of enteroscopy-assisted ERCP. The result showed that only the limb length definitely affected the therapeutic success. The authors concluded that enteroscopy-assisted ERCP should be performed in patients with a limb length of less than 150 cm, and laparoscopy-assisted ERCP should be performed when the limb length is 150 cm or longer. As enteroscopy-assisted ERCP could be performed successfully in all patients, including those with a surgical or laparoscopic gastrostomy, delaying the procedure to allow for gastrostomy maturation was not required for the majority of patients [5].

In summary, enteroscopy-assisted ERCP could be performed in most patients with previous gastric bypass surgery. We think this should be recommended as the first-line therapy, and ERCP after gastrostomy maturation should only be considered in a small selected group of patients.

• References

• 1 Law R, Wong Kee Song LM, Petersen BT et al. Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy 2013; 45: 671-675
• 2 Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005; 294: 1909-1917
• 3 Shah RJ, Smolkin M, Yen R et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 2013; 77: 593-600
• 4 Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc 2011; 25: 2592-2596
• 5 Schreiner MA, Chang L, Gluck M et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 2012; 75: 748-756
• 6 Choi EK, Chiorean MV, Coté GA et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc 2013; 27: 2894-2899