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Home , Billroth I

Altered Anatomy and

Laith H Jamil, MD, FASGE, FACG Associate Professor / Cedars Sinai Medical Center Key Points for Success

§ What is the altered anatomy? § What kind of (operative report) § Indication and what (where) do you want to reach § What scope(s) will get you there § What accessories will you need § Positioning of the patient § Sedation § Fluoroscopy § Length of procedure § Know the “expected” anatomy § Bring your dinner for evening cases! Natural Anatomical Variants

§ Zencker’s diverticulum § Malrotation of the gut § Situs Inversus Case

§ 90 + year old presents with symptoms suggestive of ascending cholangitis (Abn LFTs, confusion, hypotension, elevated WBC) § Patient intubated § Unable to advance the duodenoscope across the UES Zenker’s False Diverticulum

§ Just above the cricopharyngeal muscle § Suspect if resistance is encountered during intubation of the upper § Use a forward viewing gastroscope for evaluation and diagnosis § Exchange scope over a wire

http://headandnecksurgery.ucla.edu/body.cfm?id=127 Zenker’s False Diverticulum

§ If fail, advance a large overtube over a forward viewing gastroscope and advance the duodenoscope through the overtube Mal-rotation of the gut

§ Duodenojejunal flexure to lie to the right of the midline § Duodenal tract will be different § Should not impact ERCP significantly

https://www.med-ed.virginia.edu/courses/rad/peds/abd_webpages/abdominal16.html Situs Inversus

§ Organs in the chest and abdomen are positioned in a mirror image from their normal positions § Make sure your flouro images http://emedicine.medscape.com/article/413679-overview are correct! Types of

§ Bariatric surgeries: Restrictive, Malabsorptive, Combination § Esophageal surgeries § Antireflux surgeries § Gastric surgeries – Billroth I, Billroth II, Roux-en-Y , partial and total gastrectomy, Gastric bypass (gastrojejunostomy) without gastric resection § Duodenal Bypass Restrictive Bariatric Surgeries

§ Vertical Band Gastroplasty § Laparoscopic § Vertical Band Gastroplasty

- Normal esophagus, GE junction - Gastric pouch with banded stoma - The banded stoma is generally 10 to 12 mm in diameter - Normal distal and Huang C et al Gastro Cli N A 2005 Laparoscopic Adjustable Gastric Band

- Normal esophagus, GE junction - Proximal gastric pouch - Impression of the band - Normal distal gastric pouch and duodenum Sleeve Gastrectomy

- Normal esophagus, GE junction - Long tubular stomach - Staple line parallel to lesser curvature - Normal & duodenum ERCP in Restrictive Bariatric Surgeries

§ Better to start with a forward viewing gastroscope § If anticipate difficulty passing a duodenoscope, then dilate up to 13.5- 15 mm using a CRE balloon § Position of the duodenoscope for cannulation might be slightly different Malabsorptive

Biliopancreatic diversion ERCP not possible ERCP possible Biliopancreatic diversion and ERCP not possible Roux-en-Y Gastric Bypass (RYGB)

- Normal esophagus and GE junction - Gastric pouch (size varies) - GJ usually 10-12 mm - A short, blind limb is often visible alongside the efferent jejunal limb - The Roux limb is usually 75cm-150 cm - Bilio-Pancreatic limb length varies, usually around 40 cm

http://www.weightlosssurgery.ca/about-our- surgeries/laparoscopic-roux-en-y-gastric-bypass/ Roux-en-Y Gastric Bypass (RYGB)

§ Jejuno-jejunal (J-J) anastomosis occasionally accessible with a forward- viewing endoscope § J-J anastomosis can be side to side, or end to side (difficult intubation) ERCP in patients with Roux en Y

§ Roux-en-Y mandates use of long scope – Colonoscope – push enteroscope – DBE – SBE § Challenge is in cannulation

Courtesy of Simon K Lo Find correct lumen in J-J anastomsis

See Bile, slow down!! Remember to tattoo!

Courtesy of Simon K Lo DBE-ERCP

§ 129 DBE-ERCPs / 103 consecutive post-RYGB patients § 2 operators – Operator A (18 years of high-volume ERCP practice before acquiring DBE skill in 2004) – Operator B ( < 2 years' experience in DBE and ERCP) § DBE-ERCP success rates among patients with an intact papilla – Operator A's first (87.5 %) and last (92.9 %) 20 cases – Operator B (92.9 %) ( P = 1.00 for both)

Kashani A…. Jamil LH Endosc Int Open.2018 Jul;6(7):E885-E891 EUS-guided gastrogastrostomy-assisted ERCP

Bukhari M et al Gastrointest Endosc 2018 Sep;88(3):486-494 Esophageal Surgeries

§ Esophageal strictures post with gastric pull up (31.3%) § Diverticula or mal-alignment of the esophagus lumen can develop § If resistance to passage of a side-viewing scope, switch to a forward- viewing scope and assess path, dilated if necessary

Briel JW et al J Am Coll Surg. 198:536-542 2004 Antireflux Surgeries

§ : A short and loose 360-degree wrap is created around the distal esophagus § Partial Fundoplication – Dor: A partial anterior fundoplication usually performed following a . – Toupet: A posterior partial wrap is created by suturing the edges of the stomach to the anterior esophagus, leaving a space in between http://safesurgery.com.au/surgery/acid-reflux/ Antireflux Surgeries

§ Belsey Mark IV: A partial wrap is created through a thoracotomy by progressive invagination of the esophagus into the stomach § : Creates a tubular segment of http://clinicalgate.com/postsurgical-endoscopic-anatomy stomach in continuity to the esophagus, long enough to be encircled by a 360-degree fundoplication placed below the diaphragm § If patient has symptoms (dysphagia, nausea, vomiting, etc), consider a forward viewing scope first to evaluate http://slideplayer.com/slide/717028/ Gastric Surgeries

§ Billroth I § Billroth II § Gastric resection and Roux-en-Y § Total gastrectomy § Gastrojejunostomy without gastric resection Billroth I

§ Antrectomy and partial resection of the duodenal bulb § Major and Minor papilla are more proximal in the duodenum § Problems: – Short stomach (no antrum) – Poor scope anchor

– Papilla at acute angle http://clinicalgate.com/postsurgical-endoscopic-anatomy/ § Solutions: – Long scoping – More scope rotation Billroth II

§ Partial gastrectomy, the duodenal stump is closed and a gastrojejunostomy is created § Antiperistaltic anastomosis: The afferent limb is attached to the lesser curvature § Isoperistaltic anastomosis: The afferent limb is attached to greater curvature. http://clinicalgate.com/postsurgic al-endoscopic-anatomy/ Billroth II

§ Antecolic reconstruction: The anastomosis is anterior to the transverse colon leading to a longer afferent limb § Retrocolic reconstruction: The anastomosis passes through the mesocolon creating a shorter afferent limb

http://clinicalgate.com/postsur gical-endoscopic-anatomy/ Billroth II Isoperistaltic: Antiperistaltic: the opening the opening linked to the linked to the greater greater curvature curvature corresponds to corresponds to the afferent the efferent limb limb

Courtesy of Simon K Lo, M.D. Identifying The Afferent Limb

§ Usually the stomal opening linked to the lesser curvature is more difficult to access with the endoscope because of the relative verticalization of the anastomosis § Bile may be seen coming predominantly from the afferent limb § Visible peristaltic waves advancing away from the endoscope suggest that you’re in the efferent limb Forward or Side Viewing Scope in BII?

§ Prospective randomized study of 45 patients in Korea – Side-viewing (22 patients): cannulation (68%), sphincterotomy (80%) – Forward-viewing (23 patients): cannulation (87%), sphincterotomy (83%) – Forward-viewing endoscopes were safer to use (4 jejunal perforations in side viewing scope) § Retrospective study of 185 Billroth II ERCP procedures – Failure rate was 34% – Perforation 6%

Kim MH et al Endoscopy. 29:82-85 1997 Faylona JM et al Endoscopy. 31:546-549 1999 Tips For Using Side-Viewing Scope in BII

§ Enter the intended limb similar to the pylorus § Once the duodenoscope is into the afferent limb, orient the lumen to the 6 o’clock position § If you see 2 lumens, follow the lower one § Occasional gentle pressure by the staff maybe required § Use fluoroscopy: passage of the endoscope into the RUQ toward the or previous clips suggests entry into the afferent limb § Sometimes its too far especially if antecolic reconstruction Papilla in BII

§ The ampulla is vertically inverted (upside down) in the endoscopic image § Wire-guided Billroth II papillotome § S-shaped tip § A rotatable sphincterotome Billroth II ERCP

§ Problems: § Solutions: – What scope – Forward or side viewing – Which lumen – Try either lumen (more likely the one on the left or the more difficult one!) – Entering lumen – Gentle please – Wrong lumen – Remember where you went, leave a wire with a forward viewing scope – Check fluoro for the path – Orientating papilla – Keep papilla at 12 o'clock – Cannulating papilla – Use special cannula

Braun Modification BII

§ An anastomosis that connects the afferent and efferent limbs, usually 10-15 cm distal to the GJ § Three openings can be noted

http://clinicalgate.com/postsurgical- endoscopic-anatomy/ Gastric Resection and Roux-en-Y

§ End to side gastrojejunostomy § Short blind stump and a long Roux limb (40-60 cm before the J-J anastomosis) § Usually requires longer endoscopes

http://clinicalgate.com/postsurgical-endoscopic-anatomy/#bib37 Total Gastrectomy

§ Esophagojejunostomy § Downstream is a side-to-side or end-to-side jejunojejunostomy § Usually a side-viewing gastroscope can reach the ampulla § Position and cannulation similar

to BII https://www.halstedsurgery.org/GDL_Disease.aspx?CurrentUDV= 31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F- 79D2B9FC358&GDL_Disease_ID=DB2F8EAC-4421-41DD- B04E-684AFEF2AD94 Ding et al. BMC Surg 2015 Gastrojejunostomy Without Gastric Resection

§ Usually for gastric outlet obstruction (benign or malignant) § Duodenoscope is usually long enough to reach the duodenum

https://www.jhmicall.org/GDL_Disease.aspx?CurrentUDV=31& § The challenge is to approach the GDL_Cat_ID=AF793A59-B736-42CB-9E1F- E79D2B9FC358&GDL_Disease_ID=0ADCFD83-7DE7-4D53- papilla in the narrow lumen 82F5-6F0C9BFB7F14 § An occasional Bruan modification maybe encountered! Gastrojejunostomy Without Gastric Resection

§ Occasionally surgery performed for gastroparesis § ERCP can be performed in usual fashion § Maneuver the duodenoscope along the anterior gastric wall to avoid the gastrojejunostomy to reach the pylorus Duodeno-

§ Usually for duodenal perforation § Find 2 lumens beyond the pylorus. Identify duodenal lumen § Occasionally if there is a narrowing, might have to dilated the duodenal lumen Pancreatic surgeries

§ Whipple § Pylorus preserving Whipple § Pancreaticogastrostomy Whipple

§ Biliopancreatic limb usually at the 11o’clock § Upper endoscope or doudenoscope to reach hepaticojejunostomy Pancreaticogastrostomy

§ Stricture at anastomosis § Upper endoscope /doudenoscope § EUS guided intervention Biliary Surgeries

§ Choledochoduodenostomy § Hepaticojejunostomy secondary to biliary injury, cholangiocarcinoma, occasionally post § Cholecystojejunostomy Choledochoduodenostomy

§ Predispose to sump syndrome: – pancreatitis – cholangitis – chronic pain – obstructive jaundice

Regular upper endoscope, or doudenoscope Hepaticojejunostomy

§ Need long scope § Special accessories § Stenosis, stones, or recurrent tumor at anastomosis Summery

§ Know the anatomy your going to encounter § Prepare appropriate scopes and accessories § Be patient and gentle Know your limitations! Thank you