B0443 - The Use of a Flexible Rigidizing Overtube for Endoscopic Retrograde Cholangiopancreatography in Post-Whipple Anatomy

Monday, October 24, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

FN

Fredy Nehme, MD, MS

University of Texas MD Anderson Cancer Center
Houston, TX

Fredy Nehme, MD, MS¹, Jeffrey H. Lee, MD, MPH¹, Abraham Yu, MD², Cynthia Liu, MD¹, Faisal Ali, MD², Brian Weston, MD¹, William Ross, MD¹, Phillip Lum, ¹, Phillip Ge, MD¹, Martin Coronel, MD³, Emmanuel Coronel, MD¹
¹University of Texas MD Anderson Cancer Center, Houston, TX; ²University of Texas Health Science Center, Houston, TX; ³University of Texas MD Anderson Cancer Center, Cuenca, Azuay, Ecuador

Introduction:

Endoscopic retrograde cholangiopancreatography (ERCP) remains a technically challenging procedure in patients with altered post-surgical anatomy after pancreaticoduodenectomy (PD). The flexible rigidizing overtube (FRO) consists of a single use overtube that operates in two states, flexible or stiffened. Once the endoscope and overtube are advanced, vacuum application hardens the overtube, allowing for endoscope advancement while limiting loop formation. This device has the potential to improve endoscope stability, maneuverability, and facilitate endoscope exchange to a shorter endoscope that allows for the use of conventional ERCP accessories. This study reports our experience using the FRO for altered anatomy ERCP at a US-based academic cancer center.

Methods:

Between 1/2019 and 10/2021, patients with prior PD who underwent an ERCP were retrospectively evaluated. Data abstracted included patient demographics, procedure indication, whether the ERCP was conventional or the FRO was used, procedure-related complications, type of therapeutic interventions performed, endoscopes, and accessories used.

Results:

A total of 40 ERCPs were performed on 26 patients post pancreaticoduodenectomy. Overall technical success was achieved in 82.5% (33/40) of cases. The FRO was used in 20% (8/40) of procedures, including 1 for PJ evaluation. Failed biliary cannulation occurred in 14.3% (1/7) patients in the FRO group compared to 12.9% (4/31) cases in the conventional group. After reaching the anastomosis, a colonoscope was exchanged for a therapeutic upper endoscope for additional therapeutic interventions in 25% (2/8) of the cases when the FRO was used compared to 12.5% without the overtube (4/32). A 10 Fr plastic biliary stent was more commonly placed in the PRO group 42.8% (3/7) vs. 12.9% (4/31) in the conventional group. In patients where PJ anastomosis evaluation was the goal, the anastomosis was not reached in both cases due to a jejunal stricture preventing further endoscope advancement (one in each group). No procedure-related complications were reported.

Discussion:

This data demonstrates that the performance of ERCP can be facilitated with the use of the FRO, potentially allowing for a higher likelihood of reaching the anastomotic site and exchange to shorter endoscopes possibly allowing for more therapeutic options. Additional, larger studies are needed to evaluate this device’s efficacy, safety, and cost-effectiveness for ERCP in post-surgical anatomy.

	Flexible rigidizing overtube used (n=8)	Conventional (n=32)
Age, median (IQR)	67 (59-75)	65 (62-74)
Gender, male, n (%)	4 (50)	24 (75)
Indication
Jaundice, n (%)	1 (14.3)	3 (9.4)
Abdominal pain, n (%)	1 (14.3)	0
Cholangitis, n (%)	1 (14.3)	7 (21.9)
Abnormal liver enzymes, n (%)	4 (50)	11 (34.4)
Pancreatitis, n (%)	0	1 (3.1)
Routine stent exchange or removal, n (%)	1 (14.3)	10 (31.3)
Procedure intent
Bilio-enteric anastomosis, n (%)	7 (87.5)	31 (96.8)
Pancreaticojejunostomy, n (%)	1 (3.1)	1 (14.3)
Afferent limb reached, n (%)	8 (100)	32 (100)
Bilio-enteric anastomosis reached, n (%)	7 (100)	28 (90.3)
Pancreaticojejunostomy reached, n (%)	0	0
Cannulation success of bilioenteric anastomosis, n (%)	6 (85.7)	27 (87.1)
Exchange from colonoscope to therapeutic upper endoscope, n (%)	2 (25)	4 (12.5)
10 Fr biliary stent placed, n (%)	3 (42.8)	4 (12.9)
Balloon dilation of bilio-enteric anastomosis, n (%)	4 (57.1)	8 (25.8)
Balloon dilation of intra or extrahepatic bile ducts, n (%)	2 (28.5)	4 (12.9)

Disclosures:

Fredy Nehme indicated no relevant financial relationships.

Jeffrey Lee: Boston Scientific – Consultant.

Abraham Yu indicated no relevant financial relationships.

Cynthia Liu indicated no relevant financial relationships.

Faisal Ali indicated no relevant financial relationships.

Brian Weston indicated no relevant financial relationships.

William Ross indicated no relevant financial relationships.

Phillip Lum indicated no relevant financial relationships.

Phillip Ge indicated no relevant financial relationships.

Martin Coronel indicated no relevant financial relationships.

Emmanuel Coronel indicated no relevant financial relationships.

Fredy Nehme, MD, MS¹, Jeffrey H. Lee, MD, MPH¹, Abraham Yu, MD², Cynthia Liu, MD¹, Faisal Ali, MD², Brian Weston, MD¹, William Ross, MD¹, Phillip Lum, ¹, Phillip Ge, MD¹, Martin Coronel, MD³, Emmanuel Coronel, MD¹. B0443 - The Use of a Flexible Rigidizing Overtube for Endoscopic Retrograde Cholangiopancreatography in Post-Whipple Anatomy, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.