Carbon dioxide enterography: a useful method for double-balloon enteroscopy-assisted ERCP

Development of double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) has enabled endoscopic treatment of pancreatobiliary disease in patients with a surgically altered gastrointestinal anatomy [1]. However, scope insertion requires experience because of the maze-like gastrointestinal tract [2]. Intraluminal injection of indigo carmine to identify the afferent loop of Roux-en-Y anastomosis [3] may cause susceptibility to peristalsis and is unsuitable for complex reconstruction. To develop a smooth insertion method, we used a negative contrast technique with carbon dioxide to confirm the correct tract, termed CO₂ enterography, and we present case results here.

An 86-year-old man had previously undergone pancreatoduodenectomy had a suspected anastomotic stricture of the choledochojejunostomy. [Fig. 1 a] shows the double-balloon enteroscope at the jejunojejunostomy, after which the operator inserted the tip of the scope into one of the two tracts and injected CO₂ under the obstruction caused by scope balloon inflation. Fluoroscopy revealed CO₂ directed to the anal side ([Fig. 1 b]), indicating the incorrect tract. [Fig. 1 c] shows insertion into another tract, after which CO₂ enterography revealed the correct tract for the choledochojejunostomy. After reaching the target site, cholangiography showed no strictures ([Fig. 1 d]). In an 84-year-old man who underwent a distal gastrectomy with Billroth II reconstruction, CO₂ enterography confirmed the correct tract ([Fig. 2]). CO₂ enterography was suitable for various surgically altered gastrointestinal tract cases.

Fig. 1 a Double-balloon enteroscope at the jejunojejunostomy in an 86-year-old man who had previously undergone pancreatoduodenectomy and had a suspected anastomotic stricture of the choledochojejunostomy. b Fluoroscopy revealed CO₂ directed to the anal side, indicating the incorrect tract. c Insertion into another tract. CO₂ enterography revealed the correct tract for the choledochojejunostomy. d After reaching the target site, cholangiography showed no strictures.

Fig. 2 An 84-year-old man underwent a distalgastrectomy with Billroth II reconstruction. a CO₂ enterography confirmed the correct tract with Billroth II reconstruction. b Schema.Orange area corresponds to the afferent loop.

We retrospectively investigated target site arrival times with (n = 39) and without (n = 16) CO₂ enterography in post-surgical patients, excluding those with Billroth I reconstruction. The average time was significantly shorter in the CO₂ enterography group (26 vs. 38 minutes, P = 0.026). No adverse events related to CO₂ enterography were observed. Using CO₂ enterography, the correct tract was easily identified without wasted effort from insertion into the incorrect tract. Thus we consider it useful for insertion in DB-ERCP cases.

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• References

• 1 Shimatani M, Matsushita M, Takaoka M et al. Effective ‘short’ double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: A large series. Endoscopy 2009; 41: 849-854
• 2 Shimatani M, Takaoka M, Matsushita M et al. Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy. Dig Endosc 2014; 26 (Suppl. 01) 70-78
• 3 Yano T, Hatanaka H, Yamamoto H et al. Intraluminal injection of indigo carmine facilitates identification of the afferent limb during double balloon ERCP. Endoscopy 2012; 44: E340-E341