Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients

Table 1 Characteristics of post-surgical patients receiving push-enteroscopy or double balloon enteroscopy-endoscopic retrograde cholangiopancreatography

Pts.	Age/sex	Indication	Previous surgery	Access by G/T/P
1	72 f	Recurrent cholangitis	LTX, Roux Y, hepaticojejunostomy	No
23	76 m	Malignant cholestasis	Partial gastrectomy (BII)	No
3	60 m	Liver abscesses	Whipple resection, Roux Y, hepaticojejunostomy	P
4	66 m	Benign cholestasis	CHE, Roux Y, hepaticojejunostomy	P
53	52 f	Benign cholestasis	Complicated CHE, Roux Y, hepaticojejunostom	No
6	79 f	Postsurgical bile duct leakage	Complicated CHE partial gastrectomy (BII)	P
7	38 m	Recurrent cholangitis	Congenital bile duct atresia Roux Y, hepaticojejunostomy	No
8	66 m	Pancreatitis with pseudocyst	Pylorus preserving pancreatic head resection, Roux Y, hepatico-& pancreaticojejunostomy	No
9	58 f	Benign cholestasis abdominal pain	Total gastrectomy, Roux Y, hepaticojejunostomy	No
10	64 f	Benign cholestasis with cholangitis	CHE, right hemihepatectomy, Roux Y, hepaticojejunostomy	No
11	50 f	Benign cholestasis, bile ducht stones	Dorsal gastroenterostomy with hepaticojejunostomy	G1
12	51 f	Benign cholestasis	CHE, partial gastrectomy (BII) with Roux Y	No
13	81 f	Malignant cholestasis	CHE, partial gastrectomy (BII) with Roux Y	No
143	52 f	Benign cholestasis	Compliated CHE, Roux Y, hepaticojejunostomy	No
153	71 m	Malignant cholestasis	Complicated CHE, partial gastrectomy (BII), Roux Y	No
16	69 f	Recurrent cholangitis	CHE, Roux Y, hepaticojejunostomy	No
17	47 f	Cholangitis, malignant cholestasis	Total gastrectomy, Roux Y, hepaticojejunostom	T2
18	67 m	Benign cholestasis	LTX, bile duct revision, Roux Y, hepaticojejunostomy	No
19	51 f	Benign cholestasis, bile ducht stones	LTX, bile duct revision, Roux Y, hepaticojejunostomy	No
20	68 f	Benign cholestasis, chronic pancreatitis	Total gastrectomy, Roux Y	No
21	71 m	Recurrent cholangitis	Modified Whipple resection, Roux Y, hepaticojejunostomy	No
22	68 m	Malignant cholestasis	Partial gastrectomy (BII) with Roux Y	No
233	64 f	Malignant cholestasis	CHE, small bowel & colon resection, Roux Y, hepatico-jejunostomy	No
24	61 m	Suspected malignant cholestasis	Modified Whipple resection, Roux Y, hepaticojejunostomy	No
25	62 m	Malignant cholestasis	Total gastrectomy, Roux Y	P
26	73 m	Benign cholestasis	Pylorus preserving pancreatic head resection, Roux Y, hepatico& pancreaticojejunostomy	No
27	76 m	Benign cholestasis	Total gastrectomy, Roux Y	No
283	76 f	Malignant cholestasis	Total gastrectomy, Roux Y	No
29	84 m	Malignant cholestasis	Partial gastrectomy (BII) with Roux Y	No
30	54 m	Choledocholithiasis, cholangitis	Complicated CHE, Roux Y, choledochojejunostomy	No
31	74 m	Choledocholithiasis	Total gastrectomy, Roux Y	No
32	61 m	Recurrent cholangitis	LTX, bile duct revision, Roux Y, choledochojejunostomy	P
333	55 m	Suspected malignant cholestasis, chronic pancreatitis	Whipple resection, Roux Y, hepatico- & pancreatico-jejunostomy	No
34	34 f	Biliary colics, benign cholestasis hepatitis C	LTX, Roux Y, hepaticojejunostomy	P
353	64 m	Suspected malignant cholestasis, chronic pancreatitis	Whipple resection, Roux Y, hepatico- & pancreatico-jejnostomy	No
36	51 f	Suspected choledocholithiasis,right abdominal pain	LTX, Roux Y, choledochojejunostomy	No
37	61 m	Recurrent cholangitis	Complicated CHE, Roux Y, hepaticojejunostomy	No

¹Only after previous double balloon enteroscopy;

²Only after previous double balloon enteroscopy and by use of a short-specialised, large caliber overtube (16.8 mm);

³Patients indicate initial failure of DBE-based ERCP. G: Gastroscope; T: Side-viewing duodenoscope; P: Push-enteroscope; CHE: Cholecystectomy: BII: Billroth II resection; LTX: Liver transplantation; DBE: Double balloon enteroscopy; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 2 Results of push-enteroscopy and double balloon enteroscopy-endoscopic retrograde cholangiopancreatography: postoperative anatomy and final diagnosis

Pts.	Foot-point anastomosis (cm)	Papilla/ostium (cm)	ERCP diagnosis	PTCD before/after DBE
1	84	162	Stenotic hepaticojejunostomy (mucosal and intramural stricture 3 mm), putrid cholangitis	(2) Yes
21	67	Not found	Swelling of anastomosis, afferent loop not found	No
3	65	90	Stenotic hepaticojejunostomy (mucosal, 11 mm stricture), cholangitis	No
4 P	75	110	Sludge, stenotic hepaticojejunostomy (mucosal, 3 mm stricture)	No
51		Not found	PTCD stenotic hepaticojejunostomy (12 mm stricture)	(8) Yes(6)
6 P	52 (BII)	78	Distal bile duct leakage and adhesion to abd. drainage	No
7	80	165	Stenotic hepaticojejunostomy (mucosal, 2 mm stricture), cholangitis	No
8	85	107	Normal choledochojejunostomy pancreaticojejunostomy with 10 mm diameter, 10 mm pancreatic	No
	85	118	Duct stricture, pancreatic pseudocyst
9	85	130	Normal hepaticojejunostomy, bile duct kinking	No
10	77	142	Stenotic hepaticojejunostomy (intramural, 4 mm) and stricture, common hepatic duct 4mm, bilioma	No
11	46	62	Obstructed hepaticojejunostomy by sludge/stones (hepaticolithiasis)	No
12	70	105	Papilla stenosis, bile duct kinking and stricture 3 mm	No
13	60	84	Bile duct stricture 18 mm due to papilla tumor	Yes (2)
141	95	Not found	PTCD stenotic hepaticojejunostomy (12 mm stricture)	(12) Yes (6)
151	57	110	PTCD edematous, tumorous papilla	Yes (2)
16	65	120	Stenotic hepaticojejunostomy (mucosal, 4 mm stricture)	(10) Yes
17	65	92	Malignant proximal bile duct stricture 22 mm	No
18	100	175	Hepaticolithiasis, normal hepaticojejunostomy	No
19	70	120	Stenotic hepaticojejunostomy (intramural, 12 mm stricture), cholestasis due to bile duct bleeding	(1) Yes
20	60	78	Papilla & bile duct stenosis due to chronic, pancreatitis, pancreatic duct stenosis	No
21	55	85	Stenotic hepaticojejunostomy,(mucosal, 2 mm stricture) & intrahepatic stricture	No
22	75	110	Distal bile duct stricture 45 mm due to ampullary tumor	No
231		Not found	PTCD complete malignant stricture of hepaticojejunostomy due to progredient metastasis	Yes (1)
24	60	120	Hilar and hepatic duct strictures 9 and 26 mm, normal hepatico jejunostomy	No
25 P	65	110	Malignant obstruction biliary metal stent, sludge, cholangitis	(4) Yes
26	110	158	Stenotic hepaticojejunostomy, (intramural, 10 mm stricture)	No
27	76	112	22 mm bile duct stricture due to chronic pancreatitis	(2) Yes
281	88	145	Polypoid papilla tumor	Yes (4)
29	100	140	Distal bile duct stricture 35mm due to suspected pancreatic tumor	No
30	105	151	Bile duct with sludge, normal choledochojejunostomy	No
31	51	165	Choledocholithiasis	(2) Yes (2)
32 P	78	147	Stenotic choledochojejunostomy, (intramural, 6 mm stricture) and bilioma segment IV	No
331	66	Not found 126	PTCD: malignant stenotic hepatico-jejunostomy (filia), but normal pancreaticojejunostomy and chronic pancreatitis -	Yes (3)
	66
34 P	80	132	Stenotic hepaticojejunostomy & hilar stenosis in ischemic cholangiopathy	No
351	68	114	PTCD: recurrence of pancreatic tumor with malignant stenosis at hepaticojejunostomy, bile ducts and small intestine normal pancreaticojejnostomy and chronic pancreatitis	Yes (5)
	68	131
36	70	131	Normal choledochojejunostomy	No
37	78	139	Stenotic hepaticojejunostomy (mucosal 2mm stricture)	No

¹Patients indicate initial failure of double balloon enteroscopy (DBE)-based endoscopic retrograde cholangiopancreatography (ERCP). PTCD: Percutaneous transhepatic cholangiodrainage; PE: Push-enteroscopy.

Table 3 Results of push-enteroscopy and double balloon enteroscopy-endoscopic retrograde cholangiopancreatography: therapeutic measures and (means ± SD) of sedation, X-rays and procedure time

Pts.	Push ERCP-/DBE-ERCP		Sedation		X-ray		Procedure Time (min)
	Procedures	Therapy	Dose (mg)	Drug	Time (min)	Dose (103 cGy/cm2)
1	7	Ostium incision (snare, papillotome) dilation, 2 stents inserted, regular change of 2 stents/1 yr	12.8 ± 3 132 ± 31	Midazolam Pethidine	19 ± 11	3.4 ± 2	122 ± 158
2	1	Not successful, re-operation	10.0	Midazolam	3.3	1.0	82
			100	Pethidine
			120	Butylscopolamine
3 P	3	Ostium incision (papillotome), dilation, stent insertion, regular change of stent/1 yr	15.0 ± 1	Midazolam	7.5 ± 7	1.8 ± 1.9	115 ± 79
			125 ± 35	Pethidine
			40	Butylscopolamine
4 P	4	Stent insertion, regular change of stent/1 yr	12 ± 2	Midazolam	20 ± 29	3.1 ± 1.6	110 ± 171
			137 ± 25	Pethidine
			5	Diazepam
5	2	Not successful, PTCD	12 ± 1	Midazolam	2.8 ± 1	4.0 ± 0.2	77 ± 11
			150	Pethidine
			5	Diazepam
			40	Butylscopolamine
6 P	2	Stent insertion, closure of bile duct leakage	7.8 ± 0.4	Midazolam	4.0 ± 1	0.4 ± 0.1	135 ± 71
			100	Pethidine
7	9	Ostium incision (papillotome), 2 stents inserted, regular change of stents/1 yr	1691 ± 867	Propofol	7.1 ± 6	1.8 ± 2.4	168 ± 131
			135 ± 74	Pethidine
			40	Butylscopolamine
8	4	Bougienage pancreaticojejunostomy, stent insertion into pancreatic duct and pseudocyst; normal hepatico-jejunostomy	13.3 ± 2	Midazolam	11.8 ± 9	2.0 ± 2	161 ± 92
			158 ± 38	Pethidine
			40 ± 28	Butylscopolamine
9	1	Normal hepaticojejunostomy	14	Midazolam	10.1	0.5	91
			150	Pethidine
10	4	3 stents inserted, one change of 2 stents	11.2 ± 5	Midazolam	12.6 ± 9	0.6 ± 0.4	61 ± 12
			133 ± 28	Pethidine
11	4	Insertion nasobiliary probe, dilation, stone extraction, insertion of stent	9.5 ± 1	Midazolam	8.1 ± 2	0.7 ± 0.4	61 ± 22
			125 ± 35	Pethidine
			20	Butylscopolamine
12	8	Bougienage, papillotomy, papilla dilation 8-10mm, stent insertion, regular change of stents/18 months	1082 ± 476	Propofol	14 ± 8	3.1 ± 1.8	113 ± 97
			156 ± 77	Pethidine
			47 ± 11	Butylscopolamine
13	3	Stent insertion, regular change of stent unsuccessful due to progredient papilla tumor, PTCD	10.8 ± 3	Midazolam	13 ± 4	5.9 ± 2.9	177 ± 61
			91 ± 52	Pethidine
			40 ± 28	Butylscopolamine
14	2	Not successful, PTCD	25 ± 7	Midazolam	5.4 ± 1	0.8 ± 0.1	155 ± 21
			175 ± 35	Pethidine
15	2	Not successful, PTCD	7.8 ± 3	Midazolam	5.9 ± 2	1.5 ± 0.3	122 ± 46
			100 ± 25	Pethidine
			40	Butylscopolamine
16	1	Ostium incision (papillotome), 2 stents inserted (perforation)	14	Midazolam	15.7	1.7	155
			150	Pethidine
			5	Diazepam
17	5	Papillotomy*, bougienage, nasobiliary probe; insertion of 2 stents, regular change of 2 stents/9 mo	16.8 ± 4	Midazolam	11.6 ± 11	2.5 ± 2.6	198 ± 98
			210 ± 74	Pethidine
			16.7 ± 10	Diazepam
			30 ± 11	Butylscopolamine
18	1	Stone extraction	19	Midazolam	24.4	5.3	178
			200	Pethidine
19	4	Extraction sludge & blood coagel, insertion nasobiliary probe, extraction of percutaneous drainage & insertion of 2 stents (rendezvous), regular change of 2 stents/ 9 mo	13 ± 1	Midazolam	9.7 ± 9	2.0 ± 1.8	82 ± 31
			116 ± 28	Pethidine
			5 ± 5	Diazepam
20	4	Papillotomy, stent insertion pancreatic duct, regular change of stent/6 mo, hemostasis with injection therapy	695 ± 275	Propofol	8.7 ± 1	0.7 ± 0.4	61 ± 13
			75 ± 50	PSSSethidine
			70 ± 14	Butylscopolamine
21	3	Insertion of 2 stents, regular change of 2 stents/6 mo	12 ± 1.8	Midazolam	15 ± 7	4.5 ± 1.9	185 ± 32
			158 ± 62	Pethidine
22	1	Papillotomy, insertion of 2 stents	19	Midazolam	17.2	4.5	113
			200	Pethidine
			40	Butylscopolamine
23	1	Not successful, PTCD	16	Midazolam	0.6	0.2	63
			50	Pethidine
			20	Butylscopolamine
24	2	Stent insertion	17.5 ± 2	Midazolam	18.9 ± 15	5.6 ± 2.8	150 ± 61
			100 ± 70	Pethidine
25 P	3	Stone/sludge extraction, dilation, biliary metal stent and malignant bile duct stricture, stent insertion, regular change of stent/9 mo	9 ± 4	Midazolam	12.9 ± 2	3.3 ± 1.1	54 ± 12
			200 ± 65	Pethidine
26	2	Ostium incision (papillotome), bougienage, stent insertion	7 ± 4	Midazolam	4.5 ± 2	1.2 ± 0.6	61 ± 23
			75 ± 35	Pethidine
			40 ± 20	Butylscopolamine
27	3	Papillotomy, extraction of percutaneous drainage and insertion of 2 stents (rendezvous)	5.7 ± 1	Midazolam	5.0 ± 1	1.0 ± 0.1	71 ± 12
			83 ± 28	Pethidine
			40	Butylscopolamine
28	1	Not successful, PTCD	5	Midazolam	2.1	0.6	109
			50	Pethidine
29	2	Papillotomy, bougienage, stent insertion	9 ± 2	Midazolam	9.2 ± 2	4.4 ± 0.3	113 ± 21
			150 ± 25	Pethidine
30	1	Sludge extraction, insertion nasobiliary	2.5	Midazolam	16.4	7.8	123
			50	Pethidine
31	2	Papillotomy, stone extraction, extraction of percutaneous drainage and insertion of stent (rendezvous)	7 ± 2	Midazolam	2.2 ± 0.5	1.9 ± 0.4	96 ± 31
			100 ± 25	Pethidine
			80	Butylscopolamine
32 P	1	Stent insertion	10	Midazolam	27.1	7.9	161
			200	Pethidine
			20	Butylscopolamine
33	2	Not successful, PTCD diagnostic pancreatography, extraction of percutaneous drainage with both ostium incision and insertion of 2 stents (rendezvous)	12 ± 5	Midazolam	10.6 ± 9	3.3 ± 2.5	97 ± 80
			150 ± 70	Pethidine
			40 ± 28	Butylscopolamine
34 P	3	Insertion of 2 stents, regular change of stents/12 mo	10 ± 7	Midazolam	19.9 ± 10	3.6 ± 2.3	98 ± 33
			183 ± 124	Pethidine
			10 ± 5	Diazepam
			20 ± 20	Butylscopolamine
35	1	Not successful, PTCD diagnostic pancreatography	11	Midazolam	0.3	0.1	86
			150	Pethidine
			40	Butylscopolamine
36	1	Normal choledochojejunostomy	7	Midazolam	2.1	1.8	51
			50	Pethidine
			20	Butylscopolamine
37	1	Ostium incision (papillotome), insertion of 2 stents	8.5	Midazolam	4.4	2.0	72
			150	Pethidine
Pts overall	Total number PE/DBE		Mean sedation dose per examination		Total x-ray time	Total x-ray dose	Total examination time
37	16 PE 86 DBE		11.7 ± 2.8	Midazolam	9.0 ± 5.5	2.5 ± 1.3	111 ± 54
			124 ± 45	Pethidine
			20 ± 20	Butylscopolamine
			1156 ± 593	Propofol

P: Push-enteroscopy; ERCP: Endoscopic retrograde cholangiopancreatography; DBE: Double balloon enteroscopy; PTCD: Percutaneous transhepatic cholangiodrainage; PE: Push-enteroscopy.