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Background and aim: In surgically altered anatomy (SAA), endoscopic retrograde cholangiopancreatography (ERCP) can be challenging, and it remains debatable the choice of the optimal endoscopic approach within this context. We aim to show our experience and evaluate the technical and clinical success of endoscopic treatment performed in the setting of adverse events (AE) after pancreaticoduodenectomy (PD). Methods: This study was conducted on a retrospective cohort of patients presenting biliopancreatic complications after PD from 01/01/2012 to 31/12/2022. All patients underwent ERCP at our Endoscopy Unit. Clinical, instrumental data, and characteristics of endoscopic treatments were collected. Results: 133 patients were included (80 M, mean age = 65 y.o.) with a total of 296 endoscopic procedures (median = 2 procedures/treatment). The indications for ERCP were mainly biliary AE (76 cases, 57.1%). Technical success was obtained in 121 patients of 133 (90.9%). 112 out of 133 (84.2%) obtained clinical success. Nine patients out of 112 (8%) experienced AEs. Clinical success rates were statistically different between patients with biliary or pancreatic disease (93.4% vs 73.6%, p < 0.0001). Septic patients were 38 (28.6%) and showed a worse prognosis than non-septic ones (clinical success: 65.7% vs 91.5%, p = 0.0001). During follow-up, 9 patients (8%), experienced recurrence of the index biliopancreatic disease with a median onset at 20 months (IQR 6–40.1). Conclusion: Our case series demonstrated that the use of a pediatric colonoscope in ERCP procedures for patients with AEs after PD is both safe and effective in treating the condition, even in a long-term follow-up. [ABSTRACT FROM AUTHOR]

Background Percutaneous cholangioscopy (PerC) offers an alternative for patients with an inaccessible biliary tree. This systematic review and meta-analysis aimed to evaluate the performance of this technique. Methods A search in Medline, Cochrane and ClinicalTrials.gov databases was performed for studies assessing PerC up to October 2022. The primary outcome was diagnostic success, defined as successful stone identification or stricture workup. Secondary outcomes included therapeutic success (stone extraction, stenting) and complication rate. A subgroup analysis compared previous-generation and modern cholangioscopes. We performed meta-analyses using a randomeffects model and the results were reported as percentages with 95% confidence interval (CI). Results Fourteen studies (682 patients) were eligible for analysis. The rate of diagnostic success was 98.7% (95%CI 97.6-99.8%; I2=31.19%) and therapeutic success was 88.6% (95%CI 82.8-94.3%; I2=74.92%). Adverse events were recorded in 17.1% (95%CI 10.7-23.5%; I2=77.56%), of which 15.9% (95%CI 9.8-21.9%; I2=75.98%) were minor and 0.6% (95%CI 0.1-1.2%; I2=0%) major. The Spyglass system showed null heterogeneity for all outcomes; compared with older-generation endoscopes it offered comparable diagnostic success, but yielded significantly superior therapeutic success (96.1%, 95%CI 90-100%; I2=0% vs. 86.4%, 95%CI 79.2-93.6%; I2=81.41%; P=0.02]. Conclusion PerC, especially using currently available cholangioscopes, is associated with high diagnostic and therapeutic success. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

Background: Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce. Methods: 34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected. Results: Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple's duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m2) compared to C-ERCP (1600 ± 117 µGy*m2, p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose). Conclusions: Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex. [ABSTRACT FROM AUTHOR]

Background and Aim: The utility of a passive bending colonoscope (PBCS) in ERCP for patients with surgically altered anatomy has not been established. This study compared the outcome of PBCS-ERCP and balloon-assisted enteroscope (BAE)-ERCP. Methods: This multicenter observational study included 343 patients with surgically altered anatomy who underwent ERCP. Among these, 110 underwent PBCS-ERCP and 233 underwent BAE-ERCP. Propensity score matching was applied, and a final cohort of 210 (105 in each group) with well-balanced backgrounds was analyzed. The primary outcome was the success rate of reaching anastomosis or ampulla of Vater. Secondary endpoints included the cannulation success rate, completion rate, procedure time (to reach, cannulate, complete), and adverse events. Results: The success rate for reaching the target was 91.4% (96/105) with PBCS and 90.5% (95/105) with BAE (odds ratio [95% CI] 1.12, [0.44–2.89], P = 0.809). The mean time required to reach the target was significantly shorter in PBCS: 10.04 min (SD, 9.62) with PBCS versus 18.77 min (SD, 13.21) with BAE (P < 0.001). There were no differences in the success of cannulation or procedure completion, although the required times for cannulation and procedure completion were significantly shorter in PBCS. The incidence of adverse events was significantly higher in BAE (19.0%) than in PBCS (4.8%; P < 0.001). Conclusions: In patients with surgically altered anatomy, PBCS-ERCP showed promising results with shorter time to reach, cannulate, and a lower incidence of adverse events compared with BAE-ERCP. The success rate of reaching was favorable through PBCS compared with BAE. Clinical Trial Registration: UMIN000045546. [ABSTRACT FROM AUTHOR]

Background/Aims Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) using oblique-view EUS in patients with a surgically altered anatomy (SAA) of the upper gastrointestinal tract is limited because of difficult scope insertion due to the disturbed anatomy. This study aimed to investigate the efficiency of forward-view (FV)-EUS in performing FNA in patients with a SAA. Methods We retrospectively investigated 32 patients with a SAA of the upper gastrointestinal tract who visited Aichi Cancer Center Hospital in Nagoya, Japan, between January 2014 and December 2020. We performed-upper gastrointestinal EUS-FNA using FV-EUS combined with fluoroscopic imaging to confirm tumor recurrence or to make a decision before chemotherapy or after a failure of diagnosis by radiology. Results We successfully performed EUS-FNA in all studied patients (100% technical success), with the specificity, sensitivity, and accuracy of 100%, 87.5%, and 87.8%, respectively, with no complications. Conclusions EUS-FNA using FV-EUS combined with fluoroscopic imaging is an effective and safe technique for tissue acquisition in patients with a SAA.

Background/Aims: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) using oblique-view EUS in patients with a surgically altered anatomy (SAA) of the upper gastrointestinal tract is limited because of difficult scope insertion due to the disturbed anatomy. This study aimed to investigate the efficiency of forward-view (FV)-EUS in performing FNA in patients with a SAA. Methods: We retrospectively investigated 32 patients with a SAA of the upper gastrointestinal tract who visited Aichi Cancer Center Hospital in Nagoya, Japan, between January 2014 and December 2020. We performed upper gastrointestinal EUS-FNA using FV-EUS combined with fluoroscopic imaging to confirm tumor recurrence or to make a decision before chemotherapy or after a failure of diagnosis by radiology. Results: We successfully performed EUS-FNA in all studied patients (100% technical success), with the specificity, sensitivity, and accuracy of 100%, 87.5%, and 87.8%, respectively, with no complications. Conclusions: EUS-FNA using FV-EUS combined with fluoroscopic imaging is an effective and safe technique for tissue acquisition in patients with a SAA. [ABSTRACT FROM AUTHOR]

Objectives: Balloon enteroscopy (BE)‐assisted endoscopic retrograde cholangiopancreatography (ERCP)‐related procedures to resolve acute cholangitis (AC) in patients with surgically altered anatomy (SAA) are limited. There is a lack of evidence on whether the timing of BE‐assisted ERCP affects clinical outcomes in patients with AC. This study aimed to evaluate the clinical outcomes of short‐type single‐balloon enteroscopy (short SBE)‐assisted ERCP in patients with SAA and AC. Methods: Patients with AC who underwent short SBE‐assisted ERCP procedures between September 2011 and April 2022 were retrospectively reviewed. The outcomes of procedures undergone at ≤24 h and >24 h were compared. The primary outcome was the length of stay (LOS). Results: Overall, 56 patients underwent procedures at ≤24 h, and 58 patients at >24 h. The procedural success and adverse event rates of short SBE‐assisted ERCP were 87.7% (95% confidence interval [CI] 80.3–93.1%) and 4.4% (95% CI 1.4–9.9%), respectively. Patients with severe (Grade III) AC and systemic inflammatory response syndrome were more in early (at ≤24 h) ERCP groups. LOS and median time from ERCP procedures to discharge were shorter in the early group. Procedural success and adverse event rates between both groups had no significant differences. Multivariable linear regression analysis showed that ERCP performed at ≤24 h was associated with shorter LOS, while severe cholangitis and malignant biliary obstruction were associated with longer LOS. Conclusions: Short SBE‐assisted ERCP is effective and safe in patients with SAA and AC. Early procedures seemed to attribute early improvement of general condition, thus shortening the LOS. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound guided—pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is challenging in patients undergoing Roux-en-Y (REY) reconstruction; although balloon-assisted enteroscopy is the first-line treatment, it is not always available considering equipment and expertise. We aimed to evaluate the feasibility of using a cap-assisted colonoscope as the primary approach for ERCP in REY reconstruction. We included 47 patients with REY who underwent ERCP using a cap-assisted colonoscope between January 2017 and February 2022. The primary outcome was intubation success for ERCP using a cap-assisted colonoscope during REY reconstruction. The secondary outcomes were cannulation success, procedure-related adverse events, and variables affecting successful intubation. Comparing side-to-side jejunojejunostomy (SS-JJ) and side-to-end jejunojejunostomy (SE-JJ) groups, the intubation success rate using a cap-assisted colonoscope in the SS-JJ group was higher than that in the SE-JJ group (34 of 38 (89.5%) vs. 1 of 9 (11.1%), p < 0.001). Successful intubation was achieved in 37 (97.4%) and 8 (88.9%) patients in the SS-JJ and SE-JJ groups, respectively, after applying the rescue technique using a balloon-assisted enteroscope for failed ERCP using only a colonoscope. No perforation occurred. Multivariable analysis showed that SS-JJ was a predictive factor for successful intubation (odds ratio [95% confidence interval] = 37.06 [3.91–925.56], p = 0.005). Usage of a cap-assisted colonoscope can be crucial for ERCP in patients undergoing REY reconstruction. Anatomically, SS-JJ can facilitate easy and accurate identification of the afferent limb and a highly successful ERCP using a cap-assisted colonoscope. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography is technically challenging to perform in patients with surgically altered anatomy (SAA). For these patients, endoscopic ultrasound-guided biliary drainage (EUS-BD) is one of the good indications. The aim of our systematic review and meta-analysis was to identify and evaluate evidence of the efficacy and safety of EUS-BD in patients with SAA. A systematic review of the PubMed was conducted through to December 2021 to identify studies performing EUS-BD in patients with SAA. The primary outcome was the pooled technical success proportion in patients with SAA. The pooled clinical success and adverse event proportions in patients with SAA were also analyzed. The search identified 1195 possible records, with 18 studies meeting our criteria for analysis, reporting data for 409 patients with SAA who underwent EUS-BD. The pooled technical success, clinical success and adverse event proportions in patients with SAA were 97.8% (95% confidence interval [CI], 95.8–99.7%), 94.9% (95% CI, 91.8–98.1%), and 12.8% (95% CI, 7.4–18.1%), respectively. EUS-BD is effective for patients with SAA. However, adverse events should be considered when performing EUS-BD in these patients. [ABSTRACT FROM AUTHOR]

Background: Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce. Methods: 34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected. Results: Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple’s duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m2) compared to C-ERCP (1600 ± 117 µGy*m2, p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose). Conclusions: Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex.

Objectives: This study aimed to evaluate the trainees' practice and learning curve in short‐type single‐balloon enteroscopy (short SBE)‐assisted endoscopic retrograde cholangiopancreatography (ERCP) for patients with surgically altered anatomy (SAA) and determine how to train these trainees. Methods: The data of short SBE‐assisted ERCP procedures between September 2011 and June 2021 were analyzed. Results: Three trainees and 180 cases were included in the analysis. Each trainee performed 60 cases between April 2016 and June 2021. The trainees' completion rate was 73.9% (95% confidence interval [CI], 66.8‐80.1%). Adverse events occurred in 5.0% of cases (95% CI, 2.3‐9.3%). The trainee who experienced colonoscopy and ERCP the most achieved better outcomes of enteroscopy success (reaching the target site) and trainee's completion rates than those of the others (P =.03 and.02, respectively). The learning curve for trainee's completion showed a significant improvement after 60 cases (P =.001). Multiple logistic regression analysis indicated that Roux‐en‐Y reconstruction was the factor affecting trainees' completion failure. Conclusions: Short SBE‐assisted ERCP trainees has a substantial learning curve. If trainees do not have much experience with colonoscopy and ERCP procedures, it may be beneficial for them to start performing short SBE‐assisted ERCP procedures on non‐Roux‐en‐Y reconstruction cases. [ABSTRACT FROM AUTHOR]

Background: Malignant afferent loop obstruction (ALO) is rare condition and is difficult to manage. Endoscopic transluminal treatment has become easier with the advent of balloon-assisted enteroscopes with a large working channels and self-expandable metal stent (SEMS) with a 9 Fr delivery system. Methods: From July 2016 to March 2022, 22 patients with symptomatic malignant ALO who underwent endoscopic transluminal treatment (Initial cohort), of which 18 patients received endoscopic transluminal SEMS placement (SEMS cohort), were retrospectively evaluated. We evaluated outcomes of endoscopic transluminal treatment and long-term outcomes of SEMS placement for malignant ALO. Results: In the Initial cohort, technical and clinical success rates were both 95.5%. The median procedural time was 28.0 min. One case of guidewire-induced micro-perforation occurred as an early complication (4.5%). In the SEMS cohort, and no early complication was observed. Recurrent obstruction occurred in two cases (11.1%) during the follow-up period (median: 102 days). One was managed by additional SEMS placement and the other was treated conservatively. Conclusions: High technical and clinical success was achieved by endoscopic transluminal treatment with short procedural time for malignant ALO. Endoscopic SEMS placement also appears to be safe and effective, and additional SEMS placement can be considered in cases of re-obstruction. [ABSTRACT FROM AUTHOR]

The aim of the work: analysis and integration of literature data regarding the technical and methodological implementation of endoscopic retrograde cholangiopancreatography in altered anatomy of the gastrointestinal tract after gastric resection. Results. World literature data convincingly indicate the need for a staged approach to performing endoscopic retrograde cho langiopancreatography in patients with altered anatomy of the gastrointestinal tract. Scientific works state that the main stages are detailed examination of a past surgical history in patients, careful selection of suitable endoscopic instruments, afferent limb intubation, papilla of Vater cannulation and papillary interventions. The article describes the existing endoscopic instruments, modern techniques and approaches, their advantages and disadvantages, and the influence of various factors on the success of their use in comparison with traditional techniques for various types of surgical reconstruction for each of the above stages. The length of the afferent limb is one of the main factors that affect the success rates of the procedure. Conclusions. Endoscopic retrograde cholangiopancreatography in patients with altered anatomy is complex and faces a number of challenges. Thanks to the development of special instruments and techniques, it can be performed even in patients with a long Roux-en-Y limb, reaching therapeutic success rates close to those in patients with normal anatomy, but this requires extensive experience of an endoscopist. There are currently no clear recommendations for the use of a particular technique; therefore the choice of the optimal strategy depends on the type of surgical reconstruction, surgeon skill level and endoscopy center facilities.

Abstract Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be a challenge in patients with surgically altered anatomy. We aimed to identify the risk factors of ERCP-related adverse events in patients with surgically altered anatomy in our center. Methods We included patients with surgically altered anatomy who underwent ERCP between April 2017 and December 2020 at our center. Clinical characteristics and outcomes were analyzed in univariate and multivariate methods to identify the risk factors for adverse events. Results A total of 121 ERCP procedures were performed in 93 patients. The papilla or surgical anastomosis was successfully reached in 113 cases (93.4%). Diagnostic success was achieved in 106 cases (93.8%) and subsequent therapeutic success was achieved in 102 cases (96.2%). ERCP-related adverse events occurred in 31 cases (25.6%). In univariate analysis, not first time ERCP attempt, a CBD stone diameter ≥ 15 mm, multiple cannulation attempts, endoscopic papillary balloon dilation, endoscopic papillary large balloon dilation, endoscopic retrograde biliary drainage, biopsy in the bile duct or papilla, mechanical lithotripsy use, and stone retrieval basket were associated with ERCP-related adverse events. In multivariate analysis, multiple cannulation attempts (OR 5.283; 95% CI 1.088–25.659; p = 0.039), endoscopic papillary balloon dilation (OR 4.381; 95% CI 1.191–16.114; p = 0.026), and biopsy in the bile duct or papilla (OR 35.432; 95% CI 2.693–466.104; p = 0.007) were independently associated with ERCP-related adverse events. Conclusions ERCP in patients with surgically altered anatomy was feasible and safe. Interventions including multiple cannulation attempts, endoscopic papillary balloon dilation, and biopsy in the bile duct or papilla were independent risk factors for ERCP-related adverse events.

Background: Endoscopic radiofrequency ablation (RFA) is expected to prolong stent patency for malignant biliary obstruction (MBO). However, its feasibility when used in conjunction with a balloon enteroscope (BE) in patients with surgically altered anatomy (SAA) remains unknown. Aims: This study aimed to investigate the feasibility of RFA combined with metal stent insertion under BE guidance for MBO in patients with SAA. Methods: Thirty-seven patients who underwent treatment between October 2016 and January 2021 and met the eligibility criteria were investigated retrospectively. Study outcomes included technical and clinical success, recurrent biliary obstruction (RBO), and other adverse events besides RBO associated with RFA with metal stent placement using BE. Results: Technical and clinical success rates were 100% (37/37) each. The rates of early and late adverse events were 8.1% (3/37) and 8.1% (3/37), respectively. RBO occurred in 32.4% (12/37) of the patients, and the median time to RBO was 296 days. The cause of RBO was ingrowth in eight patients, overgrowth in three patients, and indeterminate in one patient. All reinterventions for RBO were successful using the BE approach; all ingrowths, except one, were recanalized using additional RFA without additional stent placement. The frequency of reintervention-related adverse events was 9.1% (1/11). The median time to RBO after reintervention was 166 days. Conclusions: This study demonstrated the technical safety and feasibility as well as good long-term outcomes of endobiliary RFA combined with metal stent placement under BE guidance. This approach may be a useful option for treating MBO in patients with SAA. [ABSTRACT FROM AUTHOR]

A new type of sphincterotome released to the market recently has high rotation performance and a freely bendable blade. It is devised to be singly capable of accommodating not only normal anatomy but also cases with surgically altered anatomy. This study was undertaken for clinical evaluation of the usefulness of this new sphincterotome. Eight cases in a reconstructed intestine for which cannulation or endoscopic sphincterotomy (EST) had been performed were extracted from 32 cases for which endoscopic retrograde cholangiopancreatography-related procedures were performed using the sphincterotome developed during November 2023 through February 2024. The cases were investigated retrospectively. Among these, EST was applied to six cases. Cannulation was performed using the developed sphincterotome in the native papilla in four cases. The primary endpoints were the success rate of cannulation in surgically altered anatomy and the success rate of EST. Secondary endpoints were complications and usability for operators. Usability for operators was evaluated by questionnaire for several items on a 5-point scale. EST was conducted successfully in all six cases subjected to EST. Mild hemorrhage was observed in one case (17%) as an adverse event after EST. Deep cannulation to the native papilla with the developed sphincterotome was conducted successfully in three cases (75.0%). Evaluation results by operators were 4.4 ± 0.55 for rotation performance, 4.00 ± 0.63 for incision performance, 4.29 ± 0.49 for deep cannulation performance, and 4.07 ± 0.19 for overall evaluation. In conclusion, this developed sphincterotome might be very useful for EST and cannulation in cases with surgically altered anatomy., Competing Interests: None., (© 2024 The Author(s). DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants., Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated., Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76 (90%) procedures and clinical success rate of 30/34 (88%) patients. Mild adverse event rate was 8/76 (11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30 (80%) procedures (P = 0.194 vs. biliary SBE-ERCP) and clinical success rate of 11/17 (65%) patients (P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30 (20%) (P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options., Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy., (Copyright © 2023 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved.)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically difficult. Extensive training is required to develop the ability to perform this procedure. Aims: To investigate the learning curve of single-balloon-assisted enteroscopy ERCP (SBE-ERCP). Methods: We conducted a retrospective, observational case series at a single center. We evaluated the SBE-ERCP procedures between April 2011 and February 2021. The main outcomes were the rate of reaching the target site and the success rate of the entire procedure. These parameters were additionally expressed as a learning curve. Results: A total of 687 SBE-ERCP procedures were analyzed. The learning curve was analyzed in blocks of 10 cases. In this study, seven endoscopists, experts in conventional ERCP, were included. The overall SBE-ERCP procedural success rate was 92.2% (634/687 cases). Combining all data from individual endoscopists' evaluation periods, the insertion and success rates of the SBE-ERCP procedures gradually increased with increased experience performing SBE-ERCP. The insertion success rates for the number of SBE-ERCP cases (< 20, 21–30, > 30) were 82.9%, 92.9%, and 94.3%, respectively; the procedure success rates were 74.3%, 81.4%, and 92.9%, respectively. The endoscopists who had performed > 30 SBE-ERCP cases had a success rate of ≥ 90%. Conclusions: Our results suggest that performing > 30 cases is one of the targets for conventional ERCP experts to become competent in performing SBE-ERCP in patients with a surgically altered anatomy. [ABSTRACT FROM AUTHOR]

In patients with Roux‐en‐Y (RY) reconstruction for gastric resection, the newly defined "fold disruption" (FD) sign can be useful to distinguish the afferent limb from the efferent limb at the Y anastomosis when balloon endoscopy‐assisted endoscopic retrograde cholangiopancreatography (BE‐ERCP) is performed. The FD sign was defined as endoscopic findings of the internal folds disrupted toward the afferent limb and continued toward the efferent limb at the Y anastomosis. In this prospective observational study, the accuracy of the FD sign was evaluated for those who underwent BE‐ERCP after gastric resection with RY reconstruction. Of 28 patients for whom the accuracy could be evaluated among 30 enrolled patients, the afferent limb was identified using the FD sign with 100% accuracy. For the other two patients, the scope could not reach the target lumen due to severe intestinal adhesion in one and reached the target lumen without recognition of the Y anastomosis in the other. There was no patient for whom the FD sign could not be judged for any reason, such as a blurred anastomosis line, unclear folds, sticky discharge and blood coating the surface, when the Y anastomosis was recognized. The FD sign was a highly accurate tool for distinguishing the afferent limb from the efferent limb in patients after gastric resection with RY reconstruction. This study was registered in UMIN (issued ID, UMIN000038326). [ABSTRACT FROM AUTHOR]

Background: In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era. Patients and methods: Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed. Results: At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)—in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease. Conclusion: In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result. [ABSTRACT FROM AUTHOR]

Background/Purpose: This study aimed to evaluate the feasibility of endoscopic ultrasound (EUS)‐guided antegrade covered stent placement with long duodenal extension (EASL) for malignant distal biliary obstruction (MDBO) with duodenal obstruction (DO) or surgically altered anatomy (SAA) after failed endoscopic retrograde cholangiopancreatography (ERCP). Methods: Outcomes were technical and clinical success, reintervention rate, adverse events, stent patency, and overall survival. Inverse probability of treatment weighting (IPTW) and competing‐risk analysis were performed to compare with conventional EUS‐BD. Results: Twenty‐five patients (DO, n = 18; SAA, n = 7) were included. The technical and clinical success rates were 96% and 84%, respectively. Reintervention occurred in two patients (8.3%). Adverse events occurred in six patients (24%; two cholangitis, 16%; four mild postprocedural pancreatitis [24% (n = 4/17) in patients with non‐pancreatic cancers]). The median patency was 9.4 months, and the overall survival was 2.73 months. After IPTW adjustment, the median patency in the EASL (n = 25) and conventional EUS‐BD (n = 29) were 10.1 and 6.5 months, respectively (P =.018). Conclusions: EASL has acceptable clinical outcomes with a low reintervention rate but higher rate of postprocedural pancreatitis in patients with non‐pancreatic cancers. Randomized trials comparing EASL and conventional EUS‐BD for MDBO with pancreatic cancers and DO/SAA after failed ERCP are needed to validate our findings. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be a challenge in patients with surgically altered anatomy. We aimed to identify the risk factors of ERCP-related adverse events in patients with surgically altered anatomy in our center.Methods: We included patients with surgically altered anatomy who underwent ERCP between April 2017 and December 2020 at our center. Clinical characteristics and outcomes were analyzed in univariate and multivariate methods to identify the risk factors for adverse events.Results: A total of 121 ERCP procedures were performed in 93 patients. The papilla or surgical anastomosis was successfully reached in 113 cases (93.4%). Diagnostic success was achieved in 106 cases (93.8%) and subsequent therapeutic success was achieved in 102 cases (96.2%). ERCP-related adverse events occurred in 31 cases (25.6%). In univariate analysis, not first time ERCP attempt, a CBD stone diameter ≥ 15 mm, multiple cannulation attempts, endoscopic papillary balloon dilation, endoscopic papillary large balloon dilation, endoscopic retrograde biliary drainage, biopsy in the bile duct or papilla, mechanical lithotripsy use, and stone retrieval basket were associated with ERCP-related adverse events. In multivariate analysis, multiple cannulation attempts (OR 5.283; 95% CI 1.088-25.659; p = 0.039), endoscopic papillary balloon dilation (OR 4.381; 95% CI 1.191-16.114; p = 0.026), and biopsy in the bile duct or papilla (OR 35.432; 95% CI 2.693-466.104; p = 0.007) were independently associated with ERCP-related adverse events.Conclusions: ERCP in patients with surgically altered anatomy was feasible and safe. Interventions including multiple cannulation attempts, endoscopic papillary balloon dilation, and biopsy in the bile duct or papilla were independent risk factors for ERCP-related adverse events. [ABSTRACT FROM AUTHOR]

EDEE is a relatively safe and effective procedure when performed by expert endoscopists to establish pancreaticobiliary access in patients who have failed, or are not candidates for, traditional ERCP or alternative drainage modalities. Careful preprocedural planning with attention to the patient's specific postsurgical anatomy can optimize outcomes and minimize AEs., Competing Interests: Disclosure R. Law is a consultant for ConMed and Medtronic and receives royalties from UpToDate., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: We report a case of spontaneous migration of a dedicated plastic stent after endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) in a patient with surgically altered anatomy. Patient: The patient was a male in his 70s. He underwent EUS-HGS with the successful insertion of a dedicated plastic stent and had no obvious postprocedural complications. However, nine days after the procedure, the patient visited our hospital because of abdominal pain, fever, and stent excretion. We performed EUS-HGS with antegrade stenting, after which the patient had no further complications. Conclusion: Stent migration is considered a complication requiring caution when performing EUS-HGS in patients with surgically altered anatomy., Competing Interests: The authors declare no conflicts of interest., (©2024 The Japanese Association of Rural Medicine.)

Background: Endoscopic ultrasound (EUS)-guided transhepatic antegrade stone removal (TASR) has been reserved for choledocholithiasis after failed endoscopic retrograde cholangiopancreatography (ERCP) in recent years. The aim of this study was to evaluate the techniques, feasibility, and safety of simplified single-session EUS-TASR for choledocholithiasis in patients with surgically altered anatomy (SAA)., Methods: A retrospective database of patients with SAA and choledocholithiasis from the Second Hospital of Hebei Medical University (Shijiazhuang, China) between August 2020 and February 2023 was performed. They all underwent single-session EUS-TASR after ERCP failure. Basic characteristics of the patients and details of the procedures were collected. The success rates and adverse events were evaluated and discussed., Results: During the study period, 13 patients underwent simplified single-session EUS-TASR as a rescue procedure (8 males, median age, 64.0 [IQR, 48.5-69.5] years). SAA consisted of four Whipple procedures, one Billroth II gastrectomy, four gastrectomy with Roux-en-Y anastomoses, and four hepaticojejunostomy with Roux-en-Y anastomoses. The technical success rate was 100% and successful bile duct stone removal was achieved in 12 of the patients (92.3%). Adverse events occurred in two patients (15.4%), while one turned to laparoscopic surgery and the other was managed conservatively., Conclusions: Simplified single-session EUS-TASR as a rescue procedure after ERCP failure appeared to be effective and safe in the management of choledocholithiasis in patients with SAA. But further evaluation of this technique is still needed, preferably through prospective multicenter trials., Competing Interests: The authors declare that they have no conflict of interest., (© The Author(s) 2024. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-sen University.)

Objectives Single-balloon enteroscopy (SBE)—assisted endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be cost effective and less technically demanding than other modes of device-assisted enteroscopy. We aimed to evaluate the safety and efficacy of SBE-ERCP in surgically altered anatomy. Methods This was a prospective cohort study in a high-volume tertiary care gastroenterology center. Patients with surgically altered anatomy requiring pancreaticobiliary interventions, who failed ERCP with a colonoscope/duodenoscope, underwent SBE-ERCP. Diagnostic and therapeutic success, procedure time, and adverse events were evaluated prospectively with short-term follow-up. Results Twenty-eight patients with surgically altered anatomy (19 males, aged 15–66 years) underwent total 40 SBE-ERCP (23 Roux-en-Y, 17 Billroth II anatomy) procedures. The ERCP diagnosis were hepaticojejunostomy (HJ) stricture (N = 10), HJ stricture and stone (N = 7), common bile duct (CBD) stricture (N = 6), CBD stone (N = 1), pancreaticojejunostomy (PJ) stricture (N = 1), and pancreatic duct (PD) stricture (N = 1). Diagnostic success was achieved in 91.3% (21/23) patients with Roux-en-Y anatomy and 100% (17/17) with Billroth II anatomy. Therapeutic success was achieved in 86.95% (20/23) and 94.1% (16/17) patients with Roux-en-Y and Billroth II anatomy, respectively. In patients with intact papilla (N = 8), diagnostic and therapeutic success were achieved in 100% (8/8) and 75% (6/8) cases, respectively. The mean procedure time for Roux-en-Y and Billroth II anatomy were 64.95 minutes (range 30–110 min) and 38.31 minutes (range 25–60 min), respectively. Immediate complications occurred in 7.5% (3/40) procedures (2 requiring laparotomy, 1 treated endoscopically) in the form of perforation. Among delayed complications, 5 patients had cholangitis and 1 had recurrent cholestasis, which were successfully treated with stent exchange. No other complications occurred over median follow-up of 110 days (30–390 d). Conclusion SBE-ERCP in surgically altered anatomy requiring pancreatic–biliary intervention appears safe and highly effective with current long ERCP accessories. Further improvement in SBE-ERCP technique and accessories has the potential to make it a promising avenue in surgically altered anatomy.

Objectives: With the emergence of the double‐balloon endoscope (DBE), hepaticojejunostomy anastomotic strictures (HJASs) are increasingly managed endoscopically. However, balloon dilation and/or plastic stent placement may be associated with low stricture resolution rates and long treatment duration. We utilized a fully‐covered metal stent (FCSEMS), which was designed for temporary placement for benign biliary strictures, and assessed its feasibility for patients with HJASs. Methods: We retrospectively studied 20 patients who underwent DBE‐assisted FCSEMS placement for HJASs between June 2017 and March 2019. The FCSEMS was removed endoscopically at three months of stent placement. The outcomes investigated were the stricture resolution at the time of FCSEMS removal, the stricture recurrence, and adverse events. Results: Among 20 patients treated, stricture resolution was achieved in 17 patients (85.0%) at three months of stent placement. The FCSEMS was removed endoscopically without any technical difficulties in all cases except for two with asymptomatic stent migration due to stricture resolution. During a median follow‐up period of 11.9 months (interquartile range, 7.5–18.0 months), an HJAS recurred in one patient (5.9%). For two patients without stricture resolution and one patient with recurrent stricture, another FCSEMS placement for 77, 84, and 186 days resolved the stricture. The overall stricture resolution rate was 95.0%. In one patient with FCSEMS‐induced de novo stricture, long‐term plastic stent placement was required. Procedure‐related adverse events included mild cholangitis in two patients and mild pancreatitis in one patient. Conclusions: Endoscopic treatment using a FCSEMS via DB‐ERCP was a feasible and effective treatment option for a HJAS. [ABSTRACT FROM AUTHOR]

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) has been increasingly performed for the treatment of malignant biliary obstruction (MBO) in patients with surgically altered anatomy (SAA), however evidence is scarce. Therefore, we conducted this study to evaluate the efficacy and safety of self-expandable metallic stent (SEMS) placement using a short type SBE. We retrospectively examined consecutive patients with SAA who received initial SEMS for MBO at our institution between February 2016 and February 2019. We evaluated patient characteristics, technical and functional success rates, time to recurrent biliary obstruction (TRBO) and complications according to the location of the biliary stricture. A total of 26 patients were included in this study. The primary tumor was gastric cancer in 12, pancreatic cancer in 6, cholangiocarcinoma in 6 and gallbladder cancer in 2. The biliary stricture site was distal bile duct in 14, hilar bile duct in 3 and hepaticojejunostomy (HJ) anastomosis in 9. Technical and functional success rates were 92 and 88%, respectively. TRBO, median survival time, overall rate of RBO and early complications were not different according to the stricture site (p=.36,.67,.67 and.12, respectively), whereas late complications were significantly different among the three groups (Distal vs. Hilar vs. HJ anastomosis; 0 vs. 67 vs. 22%, p<.05). Furthermore, stent patency was not different between fully covered and uncovered SEMS in distal MBO. SEMS placement via SBE-ERCP was safe and effective for the management of MBO in patients with SAA, especially in distal MBO. [ABSTRACT FROM AUTHOR]

Background: To evaluate the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO) using short-type double-balloon enteroscope (sDBE) in patients with surgically altered anatomy. Methods: A total of 45 patients with surgically altered anatomy underwent ERCP using sDBE for the treatment of MBO between April 2011 and March 2019. We retrospectively evaluated the clinical and technical success (insertion and biliary intervention success), adverse events, and risk factors for clinical failure. Results: The scope was successfully inserted in the target site in 82.2% of patients (37/45), and among them, biliary intervention success was achieved in 86.4% (32/37). The overall technical success rate was 71.1% (32/45) and clinical success rate was 68.9% (31/45), with an adverse event rate of 11.1%. In multivariate analysis, the presence of peritoneal dissemination (odds ratio, 7.3; 95% confidence interval, 1.5–43.5, p = 0.02) was as an independent risk factor for clinical failure. The clinical success rate was 38.5% in patients with peritoneal dissemination and 81.3% in those without peritoneal dissemination. Conclusion: Endoscopic treatment using sDBE in patients without peritoneal dissemination provided favorable outcomes, and it can be an initial treatment for MBO in patients with surgically altered anatomy. [ABSTRACT FROM AUTHOR]

Background: Endoscopic treatment for malignant biliary obstruction (MBO) in patients bearing surgically altered anatomy (SAA) is not well-established. Although endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a new treatment option for MBO, limited data are available regarding the efficacy and safety of EUS-BD in patients with SAA. We conducted a multicenter prospective registration study to evaluate the efficacy and safety of EUS-BD in this population. Methods: This study involved 10 referral centers in Japan. Patients with SAA who were scheduled to receive EUS-BD for unresectable MBO between May 2016 and September 2018 were prospectively registered. The primary endpoint was technical success and the secondary outcomes were clinical success, procedure time, procedure-related adverse events (AEs), stent patency, and overall survival. Results: In total, 40 patients were prospectively enrolled. The surgical reconstruction methods were gastrectomy with Roux-en-Y reconstruction (47.5%), gastrectomy with Billroth-II reconstruction (15%), pancreaticoduodenectomy (27.5%), and hepaticojejunostomy with Roux-en-Y reconstruction (10%). EUS-BD was performed for primary biliary drainage in 31 patients and for rescue biliary drainage in nine patients. Transmural stenting alone (60%), antegrade stenting alone (5%), and a combination of the two techniques (35%) were selected for patients treated with EUS-BD. Technical and clinical success rates were 100% (95% confidence interval, 91.2-100.0%) and 95% (95% confidence interval, 83.1-99.4%), respectively. Mean procedure time was 36.5 min. Early AEs were noted in six patients (15%): three self-limited bile leak, one bile peritonitis, and two pneumoperitonea. Late AEs occurred in six patients (15%): one jejunal ulcer and five stent occlusions. Stent patency rate after 3 months of survival was 95.7% (22/23). Median overall survival was 96 days. Conclusion: EUS-BD for MBO in patients with SAA appears to be effective and safe not only as a rescue drainage technique after failed endoscopic retrograde cholangiography but also as a primary drainage technique. Clinical Trial Registration: UMIN000022101 [ABSTRACT FROM AUTHOR]

Purpose of review: This review describes the recent advances and evolving techniques in endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) and highlights the novel alternative approaches for pancreato-biliary interventions in this group of patients. Recent findings: The limitations of ERCP in patients with SAA have led to the development of improved endoscopic devices and accessories, and alternative approaches for pancreato-biliary interventions. Dedicated short-type single and double balloon enteroscopes (BE) have been developed with increased maneuverability and larger accessory channels that enhance scope insertion and allow the use of various ERCP devices, respectively. In failed BE-ERCP cases, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been used to gain access to the pancreato-biliary system, with high reported procedural success. More recently, lumen-apposing metal stent (LAMS) has been used to create a temporary bridge to the excluded stomach in Roux-en-Y gastric bypass (RYGB), and the small bowel loop in other altered GI anatomy, through which conventional ERCP can be performed, with excellent preliminary results. Summary: Several novel approaches and techniques are developed and being evaluated for pancreato-biliary intervention in patients with SAA. The optimal approach should be considered based on patient history, institutional factors, and multidisciplinary collaboration. [ABSTRACT FROM AUTHOR]

Background: Short-type double-balloon endoscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) has been developed as an alternative approach for cases with a surgically altered gastrointestinal anatomy. However, this technique is sometimes technically challenging and carries a risk of severe adverse events.Aims: To evaluate the factors affecting the technical success rate and adverse events of DBE-ERCP.Methods: A total of 319 patients (805 procedures) with a surgically altered gastrointestinal anatomy underwent short DBE-ERCP. The factors affecting the technical success rate and adverse events, and the learning curve of the trainees were retrospectively evaluated.Results: The technical success rate of all procedures was 90.7%. Adverse events occurred in 44 (5.5%) procedures. A multivariate analysis indicated that Roux-en-Y reconstruction and first-time short DBE-ERCP were factors affecting the technical failure and adverse event rates, while the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction was a non-risk factor for adverse events. The trainee caseload did not affect the technical success or adverse event rates significantly; however, trainees tended to perform cases involving the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction. The success rate of scope insertion increased according to experience; however, the overall success rate did not differ to a statistically significant extent.Conclusion: Short DBE-ERCP was useful and safe for managing cases with a surgically altered anatomy; however, trainees should concentrate on accumulating experience with easy cases, such as those with the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction or a history of DBE-ERCP. [ABSTRACT FROM AUTHOR]

Background: Balloon dilation (BD) is a simple, effective procedure for postoperative benign bilioenteric strictures (BBESs). Factors associated with BBES recurrence after endoscopic BD have not been studied adequately. This study examined the outcomes and 1-year recurrence factors in patients with BBES who underwent endoscopic BD.Methods: Patients who underwent endoscopic BD as an initial treatment between April 2008 and March 2017 were retrospectively assessed. The median time to recurrence of BBES (RBBES) and recurrence factors were evaluated.Results: The study group comprised 55 patients (median age 72 years). The rate of RBBES was 52.7% (29/55), and the median time to RBBES was 2.78 years (95% confidence interval [CI] 1.17-4.40). RBBES was observed in 32.7% (18/55) within 1 year after endoscopic BD. The significant factors associated with recurrence within 1 year, revealed by multivariate analysis, were: postoperative bile leak (p = 0.001; hazard ratio [HR] 10.94; 95% CI 2.47-48.39); BBES onset within 6 months, postoperatively (p = 0.013; HR 6.18; 95% CI 1.46-26.21); no intrahepatic stones (p = 0.049; HR 3.05; 95% CI 1.01-9.22); and remaining balloon waist (p = 0.005; HR 5.71; 95% CI 1.69-19.31). The median time to RBBES was significantly shorter in patients with these recurrence factors (0.88 years vs. not reached, p = 0.004). Patients exhibiting at least two recurrence factors were significantly more likely to experience recurrence (p < 0.001).Conclusion: Endoscopic BD is effective for BBES, especially for patients with no recurrence factors. Consideration of endoscopic BD and additional treatment may be necessary for patients with recurrence factors. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) is a combination of endoscopy and fluoroscopy that is commonly used in the management of pancreatobiliary diseases. ERCP can be challenging if performed in surgically altered anatomy, such as a Billroth II reconstruction, compared with native anatomy and usually has a lower success rate. We identified five emerging challenges in such patients. These are the choice of endoscope, the identification of afferent loop, reaching the duodenal stump, cannulation in the reverse position, and endoscopic sphincterotomy. Performing ERCP in patients with a Billroth II reconstruction needs adequate knowledge, proper skill, and experience to achieve a good clinical outcome. [ABSTRACT FROM AUTHOR]

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of therapy for pancreatobiliary diseases. While ERCP is safe and highly effective in the general population, the procedure remains challenging or impossible in patients with surgically altered anatomy (SAA). Endoscopic ultrasound (EUS) allows transmural access to the bile or pancreatic duct (PD) prior to ductal drainage using ERCP-based techniques. Also known as endosonography-guided cholangiopancreatography (ESCP), the procedure provides multiple advantages over overtube-assisted enteroscopy ERCP or percutaneous or surgical approaches. However, the procedure should only be performed by endoscopists experienced in both EUS and ERCP and with the proper tools. In this review, various EUS-guided diagnostic and therapeutic drainage techniques in patients with SAA are examined. Detailed step-by-step procedural descriptions, technical tips, feasibility, and safety data are also discussed.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

Objectives  Single-balloon enteroscopy (SBE)—assisted endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be cost effective and less technically demanding than other modes of device-assisted enteroscopy. We aimed to evaluate the safety and efficacy of SBE-ERCP in surgically altered anatomy. Methods  This was a prospective cohort study in a high-volume tertiary care gastroenterology center. Patients with surgically altered anatomy requiring pancreaticobiliary interventions, who failed ERCP with a colonoscope/duodenoscope, underwent SBE-ERCP. Diagnostic and therapeutic success, procedure time, and adverse events were evaluated prospectively with short-term follow-up. Results  Twenty-eight patients with surgically altered anatomy (19 males, aged 15–66 years) underwent total 40 SBE-ERCP (23 Roux-en-Y, 17 Billroth II anatomy) procedures. The ERCP diagnosis were hepaticojejunostomy (HJ) stricture (N = 10), HJ stricture and stone (N = 7), common bile duct (CBD) stricture (N = 6), CBD stone (N = 1), pancreaticojejunostomy (PJ) stricture (N = 1), and pancreatic duct (PD) stricture (N = 1). Diagnostic success was achieved in 91.3% (21/23) patients with Roux-en-Y anatomy and 100% (17/17) with Billroth II anatomy. Therapeutic success was achieved in 86.95% (20/23) and 94.1% (16/17) patients with Roux-en-Y and Billroth II anatomy, respectively. In patients with intact papilla (N = 8), diagnostic and therapeutic success were achieved in 100% (8/8) and 75% (6/8) cases, respectively. The mean procedure time for Roux-en-Y and Billroth II anatomy were 64.95 minutes (range 30–110 min) and 38.31 minutes (range 25–60 min), respectively. Immediate complications occurred in 7.5% (3/40) procedures (2 requiring laparotomy, 1 treated endoscopically) in the form of perforation. Among delayed complications, 5 patients had cholangitis and 1 had recurrent cholestasis, which were successfully treated with stent exchange. No other complications occurred over median follow-up of 110 days (30–390 d). Conclusion  SBE-ERCP in surgically altered anatomy requiring pancreatic–biliary intervention appears safe and highly effective with current long ERCP accessories. Further improvement in SBE-ERCP technique and accessories has the potential to make it a promising avenue in surgically altered anatomy. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is one of the most challenging procedures in therapeutic endoscopy. Technical success is lower than for other therapeutic EUS procedures. However, when successful in a clear clinical indication, this procedure can offer a useful therapeutic alternative and improves the overall clinical success of the endoscopic approach. Current challenges include the standardization of clinical indications and of the techniques used for accessing the pancreatic duct, the strategy for mid-term and long-term management, and definition of the scope of the training that should be offered to a few highly experienced endoscopists., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Bile duct stones in patients with surgically altered anatomy still pose a challenge to endoscopists. For successful endoscopic management of bile duct stones, there are multiple hurdles: Intubation to the afferent limb, biliary cannulation, ampullary intervention and stone extraction. The major advancement in this area is the development of dedicated device‐assisted endoscopes for endoscopic retrograde cholangiopancreatography (ERCP). In patients with Billroth II reconstruction, a high technical success rate is reported using a duodenoscope but can be complicated by a potentially high perforation rate. In patients with Roux‐en‐Y reconstruction, device‐assisted ERCP shows high technical success and low adverse event rates. Meanwhile, endoscopic papillary large balloon dilation enables safe and effective stone extraction with less use of endoscopic mechanical lithotripsy in patients with a dilated distal bile duct, but intraductal lithotripsy is sometimes necessary for management of very large bile duct stones. In cases with difficult stones, alternative approaches such as laparoscopy‐assisted ERCP and endoscopic ultrasound (EUS)‐guided intervention are increasingly reported with preliminary but promising results. However, comparative studies are still lacking in this area and prospective randomized controlled trials are warranted in terms of safety, efficacy and cost‐effectiveness. [ABSTRACT FROM AUTHOR]

Painless jaundice is a harbinger of malignant biliary obstruction, with the majority of cases due to pancreatic adenocarcinoma. Despite advances in treatment, including improved surgical techniques and neoadjuvant (preoperative) chemotherapy, longterm survival from pancreatic cancer is rare. This lack of significant improvement in outcomes is believed to be due to multiple reasons, including the advanced stage at diagnosis and lack of an adequate biomarker for screening and early detection, prior to the onset of jaundice or epigastric pain. Close attention is required to select appropriate patients for preoperative biliary decompression, and to prevent morbid complications from biliary drainage procedures, such as pancreatitis and cholangitis. Use of small caliber plastic biliary stents during endoscopic retrograde cholangiopancreatography should beminimized, asmetal stents have increased area for improved bile flow and a reduced risk of adverse events during neoadjuvant therapy. Efforts are underway by translational scientists, radiologists, oncologists, surgeons, and gastroenterologists to augment lifespan for our patients and to more readily treat this deadly disease. In this review, the authors discuss the rationale and techniques of endoscopic biliary intervention, mainly focusing on malignant biliary obstruction by pancreatic cancer. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic retrograde cholangiography (ERCP) with biliary stenting for the treatment of unresectable malignant biliary obstruction (MBO) is challenging among patients with surgically altered anatomy. Endoscopic ultrasound-guided antegrade biliary stenting (EUS-ABS) was introduced as an alternative biliary drainage method, although it has not yet been well studied. In this single-center prospective pilot study, we aimed to evaluate the feasibility and safety of EUS-ABS for MBO in patients with surgically altered anatomy. Methods EUS-ABS for MBO was attempted in patients with surgically altered anatomy. In EUS-ABS, the bile duct in the left lobe was accessed from the intestine under EUS guidance, and a guidewire was placed. Thereafter, an uncovered metallic stent was deployed at the MBO through the fistula. All devices were then removed. Technical, clinical, and adverse event rates, as well as patient characteristics and procedure details, were evaluated. Results Twenty patients (10 women; median age, 69 years) were enrolled in the present study. Technical and clinical success rates of EUS-ABS were both 95% (19/20). In one patient, unsuccessful EUS-ABS as a result of failed visualization of the left lobe of the liver with EUS was salvaged with percutaneous biliary drainage. Rate of adverse events was 20% (4/20), including mild pancreatitis in three patients and mild fever in one patient, which were successfully managed conservatively. Conclusions EUS-ABS for MBO in patients with surgically altered anatomy was a feasible and safe procedure. Further large scale comparison studies are needed to confirm its efficacy (Clinical Trial Registration Number: UMIN000008589). [ABSTRACT FROM AUTHOR]