Clin Endosc.  2012 Nov;45(4):397-403.

Usefulness of Forward-Viewing Endoscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II Gastrectomy

• Byun JW
• Kim JW
• Sung SY
• Jung HY
• Jeon HK
• Park HJ
• Kim MY
• Kim HS
• Baik SK

Abstract

BACKGROUND/AIMS
Patients undergoing Billroth II (B II) gastrectomy are at higher risk of perforation during endoscopic retrograde cholangiopancreatography (ERCP). We assessed the success rate and safety of forward-viewing endoscopic biliary intervention in patients with B II gastrectomy.
METHODS
A total of 2,280 ERCP procedures were performed in our institution between October 2008 and June 2011. Of these, forward-viewing endoscopic biliary intervention was performed in 46 patients (38 men and 8 women with B II gastrectomy). Wire-guided selective cannulations of the common bile duct using a standard catheter and guide wire were performed in all patients.
RESULTS
The success rate of afferent loop entrance was 42 out of 46 patients (91.3%) and of biliary cannulation after the approach of the papilla was 42 out of 42 patients (100%). No serious complications were encountered, except for one case of small perforation due to endoscopic sphincterotomy site injury.
CONCLUSIONS
When a biliary endoscopist has less experience and patient volume is low, ERCP with a forward-viewing endoscope is preferred because of its ease and safety in all patients with prior B II gastrectomies. Also, forward-viewing endoscope can be used to improve the success rate of biliary intervention in B II patients.

Keyword

Billroth II gastrectomy; Endoscopic retrograde cholangiopancreatography; Forward-viewing endoscope

MeSH Terms

Catheterization
Catheters
Cholangiopancreatography, Endoscopic Retrograde
Common Bile Duct
Endoscopes
Female
Gastrectomy
Gastroenterostomy
Humans
Male
Sphincterotomy, Endoscopic

Figure

• 

  Fig. 1 The technique of wire-guided cannulation of the bile duct. (A) In patients with Billroth II gastrectomy, the ampulla was seen in a reversed position in the gastroscopic view. (B) An en face view of the papilla obtained by controlling the endoscope; a hydrophilic guidewire 0.035-inch in a diameter was preloaded into a triple lumen catheter. After minimal insertion (2 to 3 mm) of the catheter in the ampulla, the guidewire was carefully advanced through the common bile duct (CBD) under fluoroscopy until it was seen to enter the bile duct. Pushing the catheter against the duodenal wall at the 9 to 10 o'clock position or bending the tip of the endoscope (with the protruding tip of the catheter in the orifice of the papilla and upwards bending of the tip of the endoscope) led the tip of the catheter to the correct access to the CBD, i.e., at the 4 to 5 o'clock position. (C) After the catheter was removed, the guidewire was left in the lumen of CBD. (D) Endoscopic sphincterotomy by using a Soehendra Billroth II sphincterotome was performed along the guidewire directed at the 5 o'clock.

• 

  Fig. 2 Endoscopic views of common bile duct (CBD) stone removal by using only endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation (EPBD) in a patient with Billroth II gastrectomy. (A, B) After only EST of the major papilla was performed, a CBD stone was removed with a stone basket catheter. (C, D) After EPBD followed by EST, relatively large stones were easily extracted out of the bile duct with a balloon catheter.

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  Fig. 3 Needle knife fistulotomy in two patients with Billroth II gastrectomy. (A, B) After selective biliary cannulation failed, an en face view of the papilla was obtained by controlling the endoscope. After a small and deep incision was performed on the reversed roof of the ampulla by using needle knife, access to the common bile duct was obtained.

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  Fig. 4 Flow chart of the treatment results of 46 patients with Billroth II gastrectomy. CBD, common bile duct; IHD, intrahepatic bile duct; PTCS, percutaneous transhepatic choledochoscopy.

Reference

1. Baron TH, Petersen BT, Mergener K, et al. Quality indicators for endoscopic retrograde cholangiopancreatography. Gastrointest Endosc. 2006; 63(4 Suppl):S29–S34. PMID: 16564909.

2. Nakahara K, Horaguchi J, Fujita N, et al. Therapeutic endoscopic retrograde cholangiopancreatography using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy. J Gastroenterol. 2009; 44:212–217. PMID: 19214665.

3. Prat F, Fritsch J, Choury AD, Meduri B, Pelletier G, Buffet C. Endoscopic sphincteroclasy: a useful therapeutic tool for biliary endoscopy in Billroth II gastrectomy patients. Endoscopy. 1997; 29:79–81. PMID: 9101143.

4. Hintze RE, Adler A, Veltzke W, Abou-Rebyeh H. Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with billroth II or Roux-en-Y gastrojejunostomy. Endoscopy. 1997; 29:69–73. PMID: 9101141.

5. van Buuren HR, Boender J, Nix GA, van Blankenstein M. Needle-knife sphincterotomy guided by a biliary endoprosthesis in Billroth II gastrectomy patients. Endoscopy. 1995; 27:229–232. PMID: 7664700.

6. Feitoza AB, Baron TH. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part I: reconstruction without alteration of pancreaticobiliary anatomy. Gastrointest Endosc. 2001; 54:743–749. PMID: 11726851.

7. Lee TH, Park do H, Park JY, et al. Can wire-guided cannulation prevent post-ERCP pancreatitis? A prospective randomized trial. Gastrointest Endosc. 2009; 69(3 Pt 1):444–449. PMID: 19007927.

8. Faylona JM, Qadir A, Chan AC, Lau JY, Chung SC. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy. 1999; 31:546–549. PMID: 10533739.

9. Lin CH, Tang JH, Cheng CL, et al. Double balloon endoscopy increases the ERCP success rate in patients with a history of Billroth II gastrectomy. World J Gastroenterol. 2010; 16:4594–4598. PMID: 20857532.

10. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991; 37:383–393. PMID: 2070995.

11. Lin LF, Siauw CP, Ho KS, Tung JC. ERCP in post-Billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol. 1999; 94:144–148. PMID: 9934745.

12. Osnes M, Rosseland AR, Aabakken L. Endoscopic retrograde cholangiography and endoscopic papillotomy in patients with a previous Billroth-II resection. Gut. 1986; 27:1193–1198. PMID: 3781333.

13. Kim MH, Lee SK, Lee MH, et al. Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope. Endoscopy. 1997; 29:82–85. PMID: 9101144.

14. Safrany L, Neuhaus B, Portocarrero G, Krause S. Endoscopic sphincterotomy in patients with Billroth II gastrectomy. Endoscopy. 1980; 12:16–22. PMID: 7353556.

15. Kim GH, Kang DH, Song GA, et al. Endoscopic removal of bile-duct stones by using a rotatable papillotome and a large-balloon dilator in patients with a Billroth II gastrectomy (with video). Gastrointest Endosc. 2008; 67:1134–1138. PMID: 18407269.

16. Maydeo A, Borkar D. Techniques of selective cannulation and sphincterotomy. Endoscopy. 2003; 35:S19–S23. PMID: 12929049.

17. Lee YT. Cap-assisted endoscopic retrograde cholangiopancreatography in a patient with a Billroth II gastrectomy. Endoscopy. 2004; 36:666. PMID: 15243895.

18. Park CH, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS. Cap-assisted ERCP in patients with a Billroth II gastrectomy. Gastrointest Endosc. 2007; 66:612–615. PMID: 17725957.

19. Hintze RE, Veltzke W, Adler A, Abou-Rebyeh H. Endoscopic sphincterotomy using an S-shaped sphincterotome in patients with a Billroth II or Roux-en-Y gastrojejunostomy. Endoscopy. 1997; 29:74–78. PMID: 9101142.

20. Ciçek B, Parlak E, Dişibeyaz S, Koksal AS, Sahin B. Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy. J Gastroenterol Hepatol. 2007; 22:1210–1213. PMID: 17688662.

21. Jeong EJ, Kang DH, Kim DU, et al. Percutaneous transhepatic choledochoscopic lithotomy as a rescue therapy for removal of bile duct stones in Billroth II gastrectomy patients who are difficult to perform ERCP. Eur J Gastroenterol Hepatol. 2009; 21:1358–1362. PMID: 19282768.

22. Bergman JJ, van Berkel AM, Bruno MJ, et al. A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy. Gastrointest Endosc. 2001; 53:19–26. PMID: 11154484.

23. Itoi T, Ishii K, Itokawa F, Kurihara T, Sofuni A. Large balloon papillary dilation for removal of bile duct stones in patients who have undergone a billroth ii gastrectomy. Dig Endosc. 2010; 22(Suppl 1):S98–S102. PMID: 20590782.

24. Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest Endosc. 2003; 57:156–159. PMID: 12556775.

25. Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc. 2008; 67:1046–1052. PMID: 18178208.