Amer Syed, Horsley-Silva Jennifer L, Menias Christine O, Pannala Rahul
Division of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA.
Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.
Abdom Imaging. 2015 Oct;40(8):2921-31. doi: 10.1007/s00261-015-0532-7.
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass (RYGB), can be more challenging compared to those with a normal anatomy. Detailed assessment of cross-sectional imaging features by the radiologist, especially the pancreaticobiliary anatomy, strictures, and stones, is very helpful to the endoscopist in planning the procedure. In addition, any information on enteral anastomoses (for e.g., gastrojejunal strictures and afferent limb obstruction) is also very useful. The endoscopist should review the operative note to understand the exact anatomy prior to procedure. RYGB, which is performed for medically complicated obesity, is the most commonly encountered altered anatomy ERCP procedure. Other situations include patients who have had a pancreaticoduodenectomy or a hepaticojejunostomy. Balloon-assisted deep enteroscopy (single and double-balloon enteroscopy) or rotational endoscopy is often used to traverse the length of the intestine to reach the papilla. In addition, ERCP in these patients is further challenging due to the oblique orientation of the papilla relative to the forward viewing endoscope and the limited enteroscopy-length therapeutic accessories that are currently available. Overall, reported therapeutic success is approximately 70-75% with a complication rate of 3-4%. Alternative approaches include percutaneous transhepatic cholangiography, laparoscopy-assisted ERCP, or surgery. Given the complexity, ERCP in patients with surgically altered anatomy should be performed in close collaboration with body imagers, interventional radiology, and surgical services.
对于上消化道解剖结构发生手术改变的患者，如接受了Roux-en-Y胃旁路术（RYGB）的患者，与解剖结构正常的患者相比，内镜逆行胰胆管造影（ERCP）可能更具挑战性。放射科医生对横断面成像特征进行详细评估，尤其是胰胆管解剖结构、狭窄和结石情况，对内镜医生规划手术非常有帮助。此外，任何关于肠内吻合口的信息（例如，胃空肠狭窄和输入袢梗阻）也非常有用。内镜医生在手术前应查阅手术记录以了解确切的解剖结构。RYGB是为治疗复杂的肥胖症而进行的手术，是ERCP手术中最常遇到的解剖结构改变的情况。其他情况包括接受过胰十二指肠切除术或肝空肠吻合术的患者。通常使用气囊辅助深部小肠镜检查（单气囊和双气囊小肠镜检查）或旋转式内镜检查来穿越肠道到达乳头。此外，由于乳头相对于前视内镜呈倾斜方向，且目前可用的小肠镜长度的治疗附件有限，这些患者的ERCP手术更具挑战性。总体而言，报道的治疗成功率约为70%-75%，并发症发生率为3%-4%。替代方法包括经皮经肝胆管造影、腹腔镜辅助ERCP或手术。鉴于其复杂性，解剖结构发生手术改变的患者的ERCP手术应与身体成像专家、介入放射科医生和外科服务团队密切合作进行。
