ERCP in patients with prior Billroth II gastrectomy: report of 30 years’ experience

Background and study aim: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult in patients with altered anatomy following Billroth II gastrectomy. Afferent loop intubation, selective cannulation, and sphincterotomy are the main issues. Experience from a tertiary referral endoscopy center is reported.

Patients and methods: A total of 713 patients with Billroth II reconstruction who underwent ERCP between October 1982 and October 2012 were retrospectively identified from a prospectively collected database (mean age 69 ± 27 years; 567 males). The main indications for ERCP were common bile duct stones (51.2 %) and obstructive jaundice (24.8 %). Procedures were always started with a duodenoscope; in cases of failure to reach the papilla the duodenoscope was changed to a gastroscope. Endoscopic sphincterotomy was performed using a long-nose sigmoid inverted sphincterotome.

Results: The successful duodenal intubation rate was 86.7 % (618/713 patients). The main reason for intubation failure was a long and angulated afferent loop. Successful cannulation/opacification of the desired biliopancreatic duct was 93.8 % (580/618). Biliary and/or pancreatic sphincterotomy were performed in 490 (84.5 %) and 23 (4.0 %) patients, respectively. The adverse event rate was 4.3 % (45/1050 procedures). Peritoneal perforation occurred in 1.8 % of the cases (19/1050 procedures) and always required immediate surgery. Two patients died after surgery (overall mortality 0.3 %). The other adverse events resolved following conservative management or endoscopic reintervention.

Conclusions: In experienced centers, ERCP in Billroth II patients had morbidity and mortality rates that were comparable to patients with normal anatomy. The main reasons for failure were related to the inability to reach the papilla. Peritoneal perforation was the most common adverse event, and required a prompt surgical approach.

• References

• 1 Faylona JM, Qadir A, Chan AC et al. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy 1999; 31: 546-549
• 2 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
• 3 Freeman ML, Nelson DB, Sherman S et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
• 4 Masci E, Toti G, Mariani A et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001; 96: 417-423
• 5 Loperfido S, Angelini G, Benedetti G et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998; 48: 1-10
• 6 Colton JB, Curran CC. Quality indicators, including complications, of ERCP in a community setting: a prospective study. Gastrointest Endosc 2009; 70: 457-467
• 7 Howard TJ, Tan T, Lehman GA et al. Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 1999; 126: 658-663
• 8 Ciçek B, Parlak E, Dişibeyaz S et al. Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy. J Gastroenterol Hepatol 2007; 22: 1210-1213
• 9 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
• 10 Cohen SA, Siegel JH, Kasmin FE. Complications of diagnostic and therapeutic ERCP. Abdom Imaging 1996; 21: 385-394
• 11 Huibregtse K. Complications of endoscopic sphincterotomy and their prevention. N Engl J Med 1996; 335: 961-963
• 12 Costamagna G, Mutignani M, Perri V et al. Diagnostic and therapeutic ERCP in patients with Billroth II gastrectomy. Acta Gastroenterol Belg 1994; 57: 155-162
• 13 Hintze RE, Veltzke W, Adler A et al. Endoscopic sphincterotomy using an S-shaped sphincterotome in patients with a Billroth II or Roux-en-Y gastrojejunostomy. Endoscopy 1997; 29: 74-78
• 14 Wang YG, Binmoeller KF, Seifert H et al. A new guide wire papillotome for patients with Billroth II gastrectomy. Endoscopy 1996; 28: 254-255
• 15 Costamagna G, Loperfido S, Familiari P. Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction. Howell DA, Travis AC, eds. UpToDate Available from: http://www.uptodate.com/contents/endoscopic-retrograde-cholangiopancreatography-ercp-after-billroth-ii-reconstruction 2014;
• 16 Shimatani M, Matsushita M, Takaoka M et al. Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy 2009; 41: 849-854
• 17 Demarquay JF, Dumas R, Buckley MJ et al. Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Ital J Gastroenterol Hepatol 1998; 30: 297-300
• 18 Lin LF, Siauw CP, Ho KS et al. ERCP in post-Billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol 1999; 94: 144-148
• 19 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