From the Guidelines
Yes, an ERCP can be performed after a Roux-en-Y hepaticojejunostomy, but it is challenging and requires specialized techniques and equipment. The altered anatomy resulting from the surgery makes standard ERCP impossible, as conventional endoscope access to the biliary system is prevented 1.
Techniques for Challenging Anatomy
Several endoscopic approaches exist for challenging, generally postsurgical anatomy, including:
- Conventional viewing endoscopes to access the papilla in a patient’s Roux-en-Y anatomy, which has a success rate of approximately 33% 1
- Device-assisted enteroscopy using single or double balloon enteroscopes, or spiral enteroscopes, to reach the biliary-enteric anastomosis
- Percutaneous transhepatic cholangiography (PTC) with antegrade access or surgical assistance
- EUS-guided approaches, which are emerging as options, including EUS-guided placement of a fully covered metallic stent to treat stones when traditional ERCP fails 1 These procedures require specialized expertise and are typically performed at tertiary centers with experience in post-surgical biliary interventions.
Key Considerations
Key considerations for ERCP after Roux-en-Y hepaticojejunostomy include:
- Lower success rate compared to conventional ERCP (60-80% versus 90-95%) 1
- Potential complications such as bleeding, perforation, and pancreatitis
- Longer procedure time, often 60-90 minutes
- Potential need for conversion to alternative approaches if endoscopic access fails It is essential to weigh these factors and consider the individual patient's needs and anatomy when deciding on the best approach for ERCP after Roux-en-Y hepaticojejunostomy 1.
From the Research
ERCP after Roux-en-Y Hepaticojejunostomy
- ERCP can be performed after Roux-en-Y hepaticojejunostomy, but it may be technically more challenging due to the modified gastrointestinal anatomy 2, 3, 4, 5, 6.
- Several studies have reported the use of double balloon enteroscopy (DBE) and laparoscopic assisted ERCP (LAERCP) to perform ERCP in patients with Roux-en-Y hepaticojejunostomy 2, 3, 4, 6.
- The success rate of ERCP in patients with Roux-en-Y hepaticojejunostomy varies from 58% to 90%, depending on the technique and instruments used 3, 4.
- Complications can occur during ERCP in patients with Roux-en-Y hepaticojejunostomy, including perforation of the hepaticojejunostomy and retroperitoneal air 3, 6.
Techniques and Instruments
- Double balloon enteroscopy (DBE) is a useful technique for performing ERCP in patients with Roux-en-Y hepaticojejunostomy, as it allows for deeper intubation of the small intestine and better access to the biliary tree 3, 4, 6.
- Laparoscopic assisted ERCP (LAERCP) is another technique that can be used to perform ERCP in patients with Roux-en-Y hepaticojejunostomy, particularly in cases where the anatomy is complex or the patient has a history of previous surgery 2.
- The use of a transjejunal approach has been described as an alternative LAERCP technique for patients with Roux-en-Y hepaticojejunostomy 2.
Success Rates and Complications
- The overall diagnostic success rate of ERCP in patients with Roux-en-Y hepaticojejunostomy is around 82%, while the therapeutic success rate is around 58% 3.
- The success rate of ERCP in patients with Roux-en-Y hepaticojejunostomy can be improved with the use of DBE and LAERCP techniques 4.
- Complications can occur during ERCP in patients with Roux-en-Y hepaticojejunostomy, including perforation of the hepaticojejunostomy and retroperitoneal air, but these can often be managed with medical treatment or surgery 3, 6.