Retrospective Analysis Of ERCP Diagnosis And Treatment Of Biliary And Pancreatic Diseases In Patients With Surgically Altered Gastrointestinal Anatomy And Endoscopic Selection Strategy

Background Endoscopic retrograde cholangiopancreatography(ERCP)is a common and effective method for clinical diagnosis and treatment of biliary and pancreatic diseases.The endoscopic doctor delivers the endoscope through the patient's mouth to the descending duodenum through the esophagus and stomach,and finds the duodenal papilla,intubates the duodenal papilla and selectively enters the pancreaticobiliary duct and then injectes the contrast agent for diagnosis and treatment under X-ray fluoroscopy.In patients with normal anatomy,the success rate of ERCP selective intubation can reach more than95%.However,for patients with surgically altered gastrointestinal anatomy,this procedure becomes very difficult and the success rate is low because the original endoscopic approach is blocked.After Roux-e-Y reconstruction,the afferent loop is long,and it may be difficult for conventional duodenoscope to reach the target pancreaticobiliary duct.Studies have shown that after Roux-en-Y reconstruction,papillas can be reached in only33% of the patients through the duodenoscope.Once the ERCP procedures failed,these patients would have to receive palliative PTCD or more invasive surgical treatment.The advent of device-assisted enteroscopy(DAE)has greatly improved the ERCP success rate in patients with surgically altered gastrointestinal anatomy.Although there are many waysto reconstruct the digestive tract during surgery,there are four common ways that challenge ERCP procedures in our country: Billroth II subtotal gastrectomy(BII),pancreaticoduodenectomy(PD),Roux-en-Y total gastrectomy(RY-TG)and Roux-en-Y cholangiojejunostomy(RY-CJ).These four surgical methods have their own characteristics,and the lengths of the afferent loops are different.At present,duodenoscope,conventional forward-viewing endoscope(gastroscope,colonoscope)and enteroscope are all used for ERCP in patients with surgically altered gastrointestinal anatomy.In order to further understand the characteristics of ERCP in patients with surgically altered gastrointestinal anatomy,we carried out this study.Objective To evaluate the effectiveness and safety of ERCP,analyze the factors influencing the ERCP success rate and propose endoscopic selection strategies for ERCP in patients with surgically altered gastrointestinal anatomy.Methods This was a single-center retrospective study.The data of patients after ERCP treatment in our digestive endoscopy center from January 2013 to December 2018 were collected,including gender,age,causes of previous operation,surgical methods,ERCP indications,endoscopy selection,procedure time,treatment measures and complications.SPSS 19.0 was used for data analysis.Median and quartile spacing M(P25,P75)were used to express measurement data which did not obey normal distribution.Counting data were expressed by the number of cases and percentages.The comparison between counting data was tested by the chi-square test.P < 0.05 indicated that there was significant difference.The success rate and complications of ERCP in these patients and the ERCP success rate with different endoscopic procedures were analyzed.Results From January 2013 to December 2018,141 patientswith surgically altered gastrointestinal anatomy received 189 procedures in our hospital.Among them,67 patients underwent ERCP after BII(82 procedures),15 patients underwent ERCP after PD(18 procedures),18 patients underwent ERCP after RY-TG(21 procedures),41 patients underwent ERCP after RY-CJ(68 procedures).The results are as follows:1.The overall endoscopic success rate,diagnostic success rate,therapeutic success rate and ERCP success rate was 84.7%(160/189)(95%CI: 79.5%-89.8%),88.1%(141/160)(95%CI: 83.1%-93.2%),97.9%(138/141)(95%CI: 95.5%-100%)and73.0%(138/189)(95%CI: 66.6%-79.4%),respectively.The endoscopic success rate,diagnostic success rate,therapeutic success rate and ERCP success rate of BII was90.2%(74/82),87.8%(65/74),100%(65/65)and 79.3%(65/82),respectively.The endoscopic success rate,diagnostic success rate,therapeutic success rate and ERCP success rate of PD was 88.9%(16/18),87.5%(14/16),85.7%(12/14)and 66.7%(12/18),respectively.The endoscopic success rate,diagnostic success rate,therapeutic success rate and ERCP success rate of RY-TG was 76.2%(16/21),68.8%(11/16),90.9%(10/11)and47.6%(10/21),respectively.The endoscopic success rate,diagnostic success rate,therapeutic success rate and ERCP success rate of RY-CJ was 79.4%(54/68),94.4%(51/54),100%(51/51)and 75.0%(51/68),respectively.2.Complications occurred in 4 patients,including PEP(n=1),cholangitis(n=1),mucosal tear(n=1),cardiacarrest(n=1),and no other adverse events.The incidence of complications was 2.1%(4/189).3.The ERCP success rate with transparent cap was higher than that without transparent cap(80.6 % vs.46.2%)(P=0.025,OR=4.861,95% CI: 1.380-17.126),and the difference was significant.4.The ERCP success rate assisted by enteroscope was 68.4%(67/98).After successful enteroscopic insertion,the ERCP success rate through the endoscopic exchange technique was 90.5%(38/42).5.The ERCP success rate for duodenoscope,conventional forward-viewing endoscope and enteroscope after BII was 93.8%(15/16),76.2%(48/63)and 66.7%(2/3),respectively.There was no significant difference in the ERCP success rate between duodenoscope and conventional forward-viewing endoscope(P=0.225).There was no significant difference in the ERCP success rate between non-Braun's anastomosis and Braun's anastomosis(79.6% vs.78.3%,P=1.000).6.The ERCP success rate for colonoscope and enteroscope after PD was 80.0%(4/5)and61.5%(8/13),respectively.7.The ERCP success rate for gastroscope,colonoscope and enteroscope after RY-TG was50.0%(3/6),100%(1/1)and 42.9%(6/14),respectively.8.All RY-CJ patients were operated by enteroscope.The ERCP success rate was 75.0%(51/68).Conclusions ERCP is effective and safe in patients with surgically altered gastrointestinal anatomy.The ERCP success rate can be improved by using transparent cap to assist the procedure of the forward-viewing endoscope.Braun's anastomosis does not reduce the ERCP success rate of BII.Enteroscope plays an important role in ERCP of patients with surgically altered gastrointestinal anatomy.Endoscopic exchange technique can be used in the absence of long accessories.Duodenoscope is the first choice for ERCP after BII,and gastroscope or colonoscope is the second choice in cases of failure.Enteroscope is the third choice after the failure of the previous two methods.Colonoscope is the first choice for ERCP after PD and RY-TG,and enteroscope is the second choice in cases of failure.Enteroscope is the first choice for ERCP after RY-CJ.