Are balloon enteroscopy-assisted ERCP and laparoscopy-assisted ERCP in Roux-en-Y gastric bypass equivalent?

We read with interest the article on endoscopic retrograde cholangiopancreatography (ERCP) after Roux-en-Y gastric bypass (RYGB) by Tønnesen et al. [1]. The aim of their study was to assess the success of balloon enteroscopy-assisted ERCP (BEA-ERCP) and laparoscopy-assisted ERCP (LA-ERCP) after RYGB.

While no statistical difference in success was found between BEA-ERCP and LA-ERCP, the success rates in the final quintile of the study were statistically significantly higher than in the first quintile. Accumulated experience with BEA-ERCP seems less likely to predict high success rates than it does for LA-ERCP. These procedures are infrequently needed, even in high volume centers, and an extended learning curve may lead to a prolonged period to build good outcomes.

The final quintile success rate of 75 % for BEA-ERCP compares with the final quintile LA-ERCP success rate of 100 %. These differences may reflect the two distinct components for successful post-gastric bypass ERCP, namely reaching the papilla and performing the ERCP. Formation of a gastric port is a standard technique for an experienced laparoscopic surgeon, with few anatomical variables not identified on preoperative imaging. In contrast, negotiation of the small bowel and Roux loop at balloon enteroscopy may involve a range of previously unidentified variables, including adhesions. Previous studies have shown that, once the papilla has been reached with LA-ERCP, procedural success is no different from that of conventional ERCP, because the access is conventional and all therapies may be used. In BEA-ERCP, selective duct cannulation may be more challenging [2], and additional ERCP procedures may be precluded by the length or working channel characteristics of the enteroscope.

In considering the optimal approach, a multidisciplinary meeting of surgeons, radiologists, and endoscopists may be invaluable, taking account of the anatomy and endoscopic intervention predicted, along with full engagement with the patient, including a discussion of center-specific procedural outcomes. This study adds to our understanding of the management of this challenging clinical scenario.

Publication History

Article published online:
22 April 2021

• References

• 1 Tønnesen CJ, Young J, Glomsaker T. et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP after Roux-en-Y gastric bypass. Endoscopy 2020; 52: 654-661
• 2 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