肥満と減量療法のジャーナル

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The Role of Overtube-assisted Deep Enteroscopy ERCP in Roux-en-Y Gastric Bypass Patients

Mohammad F Ali, Haseeb Ahmed and Shahzad Iqbal

Bariatric surgery is the fastest growing medical intervention for obesity performed in theUS and Roux-en-Y Gastric Bypass (RYGB), is considered the "gold standard"comprising more than 60% of these cases. However, patients with surgically alteredanatomy after undergoing RYGB pose serious challenges to the endoscopist whenaccess to the biliary or pancreatic systems is required. Hurdles include reaching themajor papilla after navigating the length of the roux limb (often >100 cm) given thelimitations of standard gastroscopes and even push enteroscopes in achievingsufficient depth of insertion, orientation (upside-down configuration of the papilla), andthe lack of accessories that are actually designed for the long endoscopes required forperforming ERCPs in this patient population. To work around the aforementioned problems—specifically the length of the Rouxlimb— innovative techniques, notably overtube systems have been developed to allowthe enteroscope to reach the ampulla and perform ERCP. Three overtube-systems arepresently available: Double-balloon Enteroscopy (DBE), Single-balloon Enteroscopy(SBE), and Spiral Enteroscopy (SE). This review is designed to describe the role of these 3overtube systems in assisting with ERCP in RYGB patients based on existing literatureand evaluate their success rates in reaching the ampulla, diagnostic & therapeuticyields, and complication rates. Our review shows good success rates when comparing ability to reach ampulla (DBEERCP:83%; SBE-ERCP: 71%; SE-ERCP: 70%), diagnostic (DBE-ERCP: 77%; SBEERCP:55%; SE-ERCP: 41%) and therapeutic yields (DBE-ERCP: 75%; SBE-ERCP:81%; SE-ERCP: 68%) with low complication rates for all three systems. The sheer volume of RYGB procedures being performed and the associated predictedincrease in complications will lead to advanced endoscopists encountering morepatients with surgically altered anatomy and our review provides evidence thatovertube-assisted systems are effective and safe, and should be considered as a firstline modality in RYGB patients requiring ERCP.