Difficulties of endoscopic retrograde cholangiography after an atypical billroth ii resection

Introduction: ERCP after Billroth II gastrectomy is rarely performed and technically more difficult procedure than with normal anatomy. We have to prepare for unexpected events and changes if needed to reach the therapeutic aim.

Case study: ERCP was planned to perform in a 57 year-old female patient who complained r.u.q. abdominal pain and clinical signs of jaundice. One year before she had an atypical Billroth II resection (very small gastric stump left) because of a pT3pN2, anaplastic sigillocellular carcinoma. According to the histopathological evaluation it proved to be adenocarcinoma, with the signs of linitis plastica, with serosal perforation, abdominal metastases and acute peritonitis. She had postoperative chemo- and radiotherapy as well. Abdominal US observed sludge in the gallbladder, 11mm diameter dilatation of the choledochal duct but no signs of hepatic metastases. Obstructive enzyme elevation was seen in her laboratory parameters (seBi 106 umol/l, dir Bi 56 umol/l, gGT 560 U/l ALP 1725 U/l).

Duodenoscopy was performed with an Olympus TJF145. Afferent duodenal loop connected with a very sharp angle to the small ventricular stump. Needle knife papillotomy was needed to get the access to the bile duct. After a wire guided cannulation a very tight stricture was detected by radiography with the dilation of the proximal extrahepatic (10mm) and intrahepatic bile ducts. Insertion of a 5cm long 10F stent was the original plan but during the stenting it was stuck at 2.5cm above the papilla. We could not effort enough power because of the sharp loop angulatio. After the withdrawal of the duodenoscope with the stent stuck, we changed to a shorter 3cm long 10 F stent. With the shorter stent we were able to complete the maneuver maintaining the appropriate bile flow. Two days later choledochal duct diameter was 7.3mm and the stent was in the right position by US, enzyme levels declined (seBi 30 umol/l, dirBi 13 umol/l, gGT 335 U/l, ALP 1350 U/l) and the patient was clinically in stable condition.

Conclusion: with this case we intended to point out that ERCP after BiIIrothresection is a difficult and mostly individual procedure sometimes requiring careful but quick decisions and change of the original plan.