Matthew J. Skinner

ERCP with the overtube-assisted enteroscopy technique: a systematic review

BACKGROUND AND STUDY AIM Overtube-assisted enteroscopy (OAE) techniques have increased the ability to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass. The aim of this study was to compare the efficacy and safety of OAE-ERCP in patients with different configurations of upper gastrointestinal anatomy. PATIENTS AND METHODS A systematic review was performed following a literature search for papers published between 1966 and August 2013. The following databases were searched: MEDLINE (via PubMed), Embase, Cochrane library, and Scopus. The following end points were analyzed: diagnostic and therapeutic success rates, cannulation success rate, ERCP success rate, type of enteroscopy, types of intervention, complications. RESULTS A total of 23 relevant reports on OAE procedures, including single-balloon, double-balloon, and spiral enteroscopy, were analyzed. Studies included a total of 945 procedures in 679 patients (age 2 - 91 years) who had a variety of postsurgical upper gastrointestinal anatomical configurations. Among patients who underwent Roux-en-Y with gastric bypass, endoscopic success was 80 % and ERCP success was 70 %. In patients who had undergone a Roux-en-Y with either a pancreaticoduodenectomy, pylorus-preserving pancreaticoduodenectomy, or hepaticojejunostomy, endoscopic success was 85 % and ERCP success was 76 %. In patients who had undergone a Billroth II procedure, endoscopic success was 96 % and ERCP success was 90 %. In patients with native papilla who underwent successful endoscopy, cannulation was successful in 90 % of patients compared with 92 % in patients with an anastomosis. Overall ERCP success for all attempts was approximately 74 %. Interventions included sphincterotomy, pre-cut papillotomy, anastomotic stricturoplasty, stone removal, stent insertion, stent replacement, and balloon dilation of stenotic anastomosis. There were 32 major complications among the 945 procedures (3.4 %). CONCLUSION Both endoscopic and ERCP success rates were highest in patients with Billroth II anatomy, followed by those with pancreaticoduodenectomy and Roux-en-Y hepaticojejunostomy; the lowest success rates were in patients with Roux-en-Y gastric bypass. Cannulation rates appeared to be equivalent in patients with both native papilla and biliary-enteric or pancreaticoenteric anastomoses. The diagnostic and therapeutic potential of balloon-assisted ERCP were high and the adverse event rate was low.

Using balloon-overtube-assisted enteroscopy for postoperative endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is technically more challenging in patients with postsurgical anatomy such as Roux-en-Y anastomosis, frequently mandating an operative intervention. Although limited, there is growing evidence that ERCP can be performed using the balloon-overtube-assisted enteroscopy (BOAE) in patients with complex postoperative anatomy. We present the technical aspects of performing ERCP with the BOAE in patients presenting with complex postsurgical anatomy having biliary problems. ERCP using the BOAE is feasible in patients with complex postsurgical anatomy, permitting diagnostic and therapeutic interventions in 80% of patients.

A simply placed percutaneous intragastric trocar for use of laparoscopic tools in endoscopy.

The performance of transoral therapy is limited by the eed to achieve triangulation for tissue exposure, dissection, nd instrumentation and by the small channel size of an endocope. A novel transgastric trocar (EndoTAGSS, Kansas City, ansas, USA) is explained in this video (Video 1, available nline at www.giejournal.org) and is used in a porcine odel with a proven endoscopic technique analogous to ercutaneous endoscopic gastrostomy (PEG) tube lacement. The device allows for triangulation and novel ntralumenal techniques in a dual endoscopic/laparoscopic c t P e t T f a s f g t U l T i r f d Figure 1. The percutaneous intragastric troc

Long-term successful closure of a percutaneous intragastric trocar tract with crossing full-thickness sutures in a porcine model

BACKGROUND AND STUDY AIMS A novel intragastric trocar placed using a percutaneous endoscopic gastrostomy technique enables the use of laparoscopic tools and procedures, including tissue stapling, cutting, suturing, and retraction. The aim of this porcine study was to determine long-term success of crossing full-thickness sutures in closure of the tract upon trocar withdrawal. METHODS 10 trocars were placed in 5 animals. Each animal underwent a standardized tissue resection using a 5-mm stapler under gastroscopic guidance, and two full-thickness, absorbable, crossing sutures were used to close the trocar tracts. The animals were monitored for 35 days and then euthanized for necropsy. RESULTS All five animals survived without sign of infection or distress. Nine of the 10 trocar sites healed completely without any adverse findings. A single site developed a gastrocutaneous fistula. On necropsy, there was no evidence of intra-abdominal infection or abscess. CONCLUSIONS Full-thickness crossing sutures appeared to be effective in long-term closure of an intragastric trocar tract. Given the ease of placement and success of this simple closure method, this device may prove clinically useful to the endoscopist performing complex procedures in the endoscopy suite.