Reply to Fan et al.
25 July 2014 (online)
As pointed out by Fan et al., endoscopic retrograde cholangiopancreatography (ERCP) can be performed using a variety of techniques in patients with Roux-en-Y gastric bypass (RYGB) anatomy. However, we believe each technique has substantial limitations. ERCP performed after laparoscopic  or radiologic  access to the gastric remnant requires schedule coordination, which may further delay a needed procedure. We do acknowledge that ERCP with laparoscopic assistance may be feasible in centers where surgeons also perform ERCP. It should be noted that our technique does not require gastrostomy tract maturation, as gastropexy is performed prior to gastrostomy creation. This allows immediate use of the gastrostomy tract.
In our experience, ERCP performed using balloon-assisted enteroscopy (BAE) can be successful but in many cases is time consuming and produces inconsistent results. Fan et al. poignantly state that limb length may be the only limiting factor to successful ERCP using BAE . Regardless of limb length, certain clinical scenarios (i. e. sphincter of Oddi dysfunction) demand maximal sphincterotomy, which is difficult to achieve with a forward-viewing endoscope due to lack of an en face view of the papilla and lack of an elevator . Thus, we believe our technique is superior in this setting.
We believe that the percutaneous-assisted transprosthetic endoscopic therapy (PATENT) technique  has several additional advantages over previously identified techniques. The technique has the benefit of direct visualization during gastrostomy creation, allowing us to choose an optimal site for subsequent ERCP. In contrast to laparoscopic-assisted ERCP, the gastrostomy tract allows access following initial ERCP. This allows the second duodenum to be reached easily using either a forward-viewing gastroscope or a side-viewing duodenoscope in the event of post-sphincterotomy bleeding and/or the need to remove a retained prophylactic pancreatic duct stent. Not all endoscopists are trained in deep enteroscopy techniques and thus enteroscopy-trained endoscopists may not be readily available should adverse events related to the sphincterotomy arise.
In summary, we believe that the PATENT technique is a viable option for any indication in patients with RYGB anatomy and is superior to ERCP after laparoscopic or radiologic access. We acknowledge that ERCP using BAE may be successful in patients with certain noncomplex clinical scenarios (i. e. choledocholithiasis, malignant biliary obstruction); however, the PATENT technique should be strongly considered in complex cases (i. e. malignant hilar obstruction, primary sclerosing cholangitis, sphincter of Oddi dysfunction).
- 1 Baron TH, Vickers SM. Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Gastrointest Endosc 1998; 48: 640-641
- 2 Tekola B, Wang AY, Ramanath M et al. Percutaneous gastrostomy tube placement to perform transgastrostomy endoscopic retrograde cholangiopancreaticography in patients with Roux-en-Y anatomy. Dig Dis Sci 2011; 56: 3364-3369
- 3 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
- 4 Saleem A, Levy MJ, Petersen BT et al. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 2012; 16: 203-208
- 5 Law R, Wong Kee Song LM, Petersen BT et al. Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series. Endoscopy 2013; 45: 671-675