Clin Endosc.  2015 Sep;48(5):421-427. 10.5946/ce.2015.48.5.421.

Efficacy and Safety of Endoscopic Papillary Balloon Dilation Using Cap-Fitted Forward-Viewing Endoscope in Patients Who Underwent Billroth II Gastrectomy

• Jang JS
• Lee S
• Lee HS
• Yeon MH
• Han JH
• Yoon SM
• Chae HB
• Youn SJ
• Park SM

• KMID: 2148554
• DOI: http://doi.org/10.5946/ce.2015.48.5.421

Abstract

BACKGROUND/AIMS
Endoscopic exploration of the common bile duct (CBD) is difficult and dangerous in patients with Billroth II gastrectomy (B-II). Endoscopic papillary balloon dilation (EPBD) via a cap-fitted forward-viewing endoscope has been reported to be an effective and safe procedure. We analyzed the technical success and complications of EPBD in patients who underwent B-II.
METHODS
Thirty-six consecutive patients with B-II were enrolled from among 2,378 patients who had undergone endoscopic retrograde cholangiopancreatography in a single institute in the last 4 years. The EPBD procedure was carried out using a cap-fitted forward-viewing endoscope with 8-mm balloon catheters for 60 seconds. We analyzed the rates of CBD exploration, technical success, and complications.
RESULTS
Afferent loop intubation was performed in all patients and selective cannulation of the bile duct was performed in 32 patients (88.9%). Complications such as transient hypoxia were observed in two patients (5.6%) and perforation, in three patients (9.7%). The perforation sites were ductal injury in two patients and one patient showed retroperitoneal air alone without symptoms. Three patients manifested different clinical courses of severe acute pancreatitis and peritonitis, transient abdominal pain, and retroperitoneal air alone. The condition of one patient improved with surgery and that of the other two patients, with conservative management.
CONCLUSIONS
Patients with perforation during EPBD in B-II showed different clinical courses. Tailored treatment strategies are necessary for improving the clinical outcomes.

Keyword

Perforation; Endoscopic papillary balloon dilation; Billroth II gastrectomy; Cap-fitted; Forward-viewing endoscopy

MeSH Terms

Abdominal Pain
Anoxia
Bile Ducts
Catheterization
Catheters
Cholangiopancreatography, Endoscopic Retrograde
Common Bile Duct
Endoscopes*
Gastrectomy*
Gastroenterostomy*
Humans
Intubation
Pancreatitis
Peritonitis

Figure

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  Fig. 1 (A) Endoscopic view of a papillary balloon dilation through the transparent cap. The ampulla is seen in a reversed position in the cap-fitted forward endoscopic view in patients who had undergone Billroth II gastrectomy. (B) Endoscopic papillary balloon dilatation. The balloon is located over a guide-wire and inflated and dilation took 60 seconds.

• 

  Fig. 2 The changes in white blood cell (WBC) count and body temperature in three patients with perforation. Compared to patient 1, who showed high fever and leukocytosis, patients 2 and patient 3 remained in a normal state during their hospital stay.

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  Fig. 3 Endoscopic retrograde cholangiopancreatography findings of endoscopic view and cholangiography and computed tomography (CT) findings after perforations in three patients with Billroth II gastrectomy (A-C, patient 1; D-F, patient 2; G-I, patient 3). (A) A slit-like papillary orifice was seen in a reversed major papilla. (B) A single common bile duct (CBD) stone was seen in an angulated and narrowed distal CBD. (C) An abdominal CT showed massive fluid and air collection at the retroperitoneal space. (D) Periampullary diverticulum. (E) Distal CBD stenosis. (F) An abdominal CT revealed minimal air leak at the retroperitoneal space. (G) A papillary orifice with reversed major papilla. (H) A fluoroscopy showed a single round CBD stone and retroperitoneal air. (I) An abdominal CT showed massive air leakage without fluid accumulation in the retroperitoneal space.

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  Fig. 4 (A, B) Normal histology of the sphincter of Oddi at the oral protrusion inside the muscle layer of the duodenum. The bile duct was surrounded by the dense and thick sphincter of Oddi (A, H&E stain, ×40; B, H&E stain, ×100). (C) Normal histology of the bile duct outside the duodenal wall (H&E stain, ×100). The bile duct is surrounded by the rough and thin sphincter of Oddi, which has partly disappeared on the side of the parenchyma of the pancreas. The blue and translucent circle, 8 mm in diameter, denotes maximal inflation of the balloon.

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