ERCP for patients who have undergone Billroth Ⅱ gastroenterostomy and Braun anastomosis

Endoscopic retrograde cholangiopancreatography(ERCP)is efficacious in patients who have undergone Billroth Ⅱ gastroenterostomies,but the success rate decreases in patients who also have experienced Braun anastomoses.There are currently no reports describing the preferred enterography route for cannulation in these patients.We first review the patient’s previous surgery records,which most often indicate that the efferent loop is at the greater curvature of the stomach.We recommend extending the duodenoscope along the greater curvature of the stomach and then advancing it through the"lower entrance"at the site of the gastrojejunal anastomosis,along the efferent loop,and through the"middle entrance"at the site of the Braun anastomosis to reach the papilla of Vater.Ten patients who had each undergone BillrothⅡgastroenterostomy and Braun anastomosis between January 2009 and December 2011 were included in our study.The overall success rate of enterography was 90% for the patients who had undergone BillrothⅡgastroenterostomy and Braun anastomosis,and the therapeutic success rate was 80%.We believe that this enterography route for ERCP is optimal for a patient who has had BillrothⅡgastroenterostomy and Braun anastomosis and helps to increase the success rate of the procedure.     

Retrieval-balloon-assisted enterography for ERCP after Billroth II gastroenterostomy and Braun anastomosis

AIM: To describe an optimal route to the Braun anastomosis including the use of retrieval-balloon-assisted enterography.METHODS: Patients who received a Billroth II gastroenterostomy (n = 109) and a Billroth II gastroenterostomy with Braun anastomosis (n = 20) between January 2009 and May 2013 were analyzed in this study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed under fluoroscopic control using a total length of 120 cm oblique-viewing duodenoscope with a 3.7-mm diameter working channel. For this procedure, we used a triple-lumen retrieval balloon catheter in which a 0.035-inch guidewire could be inserted into the “open-channel” guidewire lumen while the balloon could be simultaneously injected and inflated through the other 2 lumens.RESULTS: For the patients with Billroth II gastroenterostomy and Braun anastomosis, successful access to the papilla was gained in 17 patients (85%) and there was therapeutic success in 16 patients (80%). One patient had afferent loop perforation, but postoperative bleeding did not occur. For Billroth II gastroenterostomy, there was failure in accessing the papilla in 15 patients (13.8%). ERCP was unsuccessful because of tumor infiltration (6 patients), a long afferent loop (9 patients), and cannulation failure (4 patients). The papilla was successfully accessed in 94 patients (86.2%), and there was therapeutic success in 90 patients (82.6%). Afferent loop perforation did not occur in any of these patients. One patient had hemorrhage 2 h after ERCP, which was successfully managed with conservative treatment.CONCLUSION: Retrieval-balloon-assisted enterography along an optimal route may improve the ERCP success rate after Billroth II gastroenterostomy and Braun anastomosis.     

Therapeutic endoscopic retrograde cholangiopancreatography using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy

Background  Prior Billroth II gastrectomy is an important factor presenting difficulties in endoscopic retrograde cholangiopancreatography (ERCP) administration. We retrospectively evaluated the usefulness and safety of therapeutic ERCP using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy. Methods  Forty-three patients with bile duct stones after Billroth II gastrectomy who underwent ERCP from January 1998 to February 2008 were enrolled in this study. We used anterior oblique-viewing endoscopes for all procedures. Endoscopic sphincterotomy was performed using a needle knife guided by a biliary stent. A total of 808 patients without gastrectomy who had undergone ERCP for bile duct stones in the same period were reviewed as controls. Results  The success rate of access to the papilla of Vater was 88.4%, and the average time required for such access was 13 min. In cases of successful access, selective cannulation of the bile duct and complete stone removal were achieved in 94.7% and 94.6% of patients, respectively. The incidence of complications was 4.7%. As for the success rate of selective cannulation, complete stone removal ratio, and the incidence of complications, there were no significant differences compared with the control group. Conclusions  Use of an anterior oblique-viewing endoscope enables good success rates in selective cannulation and complete stone removal to be achieved in patients with prior Billroth II gastrectomy. The safety of therapeutic ERCP for removal of bile duct stones in those patients is comparable to that in patients with normal anatomy.     

Endoscopic papillary large balloon dilation in Billroth II gastrectomy patients with bile duct stones

Background and Aims: Patients with Billroth II (B‐II) gastrectomy present technical difficulties during endoscopic stone removal due to altered anatomy. Although endoscopic sphincterotomy alone or endoscopic balloon dilation alone has been used for removal of bile duct stones in patients with B‐II gastrectomy, the results are not satisfactory. The aim of this study was to evaluate the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) for removal of bile duct stones in patients with B‐II gastrectomy. Methods: Twenty‐six patients (20 men and six women; median age 72 years) with bile duct stones and a history of B‐II gastrectomy were enrolled. After cannulation, limited endoscopic sphincterotomy was performed. Then, balloon dilation (balloon size, 10–15 mm) was performed and stones were removed conventionally or via mechanical lithotripsy. Successful stone removal and complications were evaluated. Results: In all cases, stones were successfully removed. The median number of sessions for complete stone removal was one (range 1–3). Stone removal by mechanical lithotripsy was achieved in three patients (11.5%). There were no significant complications, such as bleeding, pancreatitis, or perforation. Conclusions: Endoscopic papillary large balloon dilation is an effective and safe method for removal of bile duct stones. We suggest consideration of this technique for removal of bile duct stones in patients with B‐II gastrectomy.     

Endoscopic retrograde cholangiopancreatography in infants and children

A single institutional experience with endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients was reviewed, focusing on the method of anesthesia, choice of an endoscope, indications, and complications. The medical records of 50 ERCPs performed in 42 infants and children (14 male and 28 female) were reviewed retrospectively. The patients' ages ranged from 57 days to 15 years. Forty-four ERCPs were diagnostic and 6 were therapeutic, including incision of choledochocele, and sphincterotomy and extraction of pancreatic stones. All procedures were successful. The most common indication for ERCP was to evaluate congenital biliary dilatation, in 28 patients (67%). Mild cholangitis occurred as a complication in 1 patient, but was alleviated with medication. A conventional duodenoscope could be used in patients older than 10 years. A pediatric duodenoscope was always used in patients under 1 year of age. Either type was chosen individually for those aged 1 to 10 years depending on the purpose, diagnostic or therapeutic. It is noteworthy that ERCP and/or sphincterotomy in a 1-year-old infant and two 2-year-old children were safely performed with the conventional endoscope. General anesthesia was employed in those younger than 9 years and intravenous sedation and local anesthesia in those older than 11 years. For children aged 9 to 11 years, anesthesia was chosen individually. We concluded that ERCP is a relatively easy and safe technique even for infants and children when performed by skilled hands with an appropriate duodenoscope under suitable anesthesia. The minimum age for use of the conventional duodenoscope may be 1 year. Received: February 1, 1999 / Accepted: July 23, 1999     

Survey of informed consent for endoscopic retrograde cholangiopancreatography

Prior to performance of gastrointestinal endoscopic procedures, physicians are generally required to apprise patients of potential risks, benefits, and alternatives. Components of the informed consent process require that: (1) consent be voluntary; (2) the patient be sufficiently mentally capable to engage in rational decision-making; and (3) adequate information be conveyed. Controversies reflected in both medical and legal literature concern the definition of adequate information. To sample current opinion regarding consent for both diagnostic and therapeutic ERCP, members of the Indiana Gut Club and Midwest Gut Club were polled. From this group of academic and private practice physicians, 81 completed evaluations were compiled. Greater than 90% of physicians believed that pancreatitis and pancreatitis/bleeding/perforation must be mentioned for diagnostic and therapeutic ERCP, respectively. There was variation of opinion as to whether patients must be informed of potential need for surgery, prolonged hospital stay, or death. The performing physician was felt to be ultimately responsible for obtaining consent, although other health-care team members, excluding a secretary, could participate.     

Efficacy and safety of endoscopic retrograde cholangiopancreatography in patients with Billroth II anastomosis

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) procedure is quite difficult to perform in patients with Billroth II anastomosis because of anatomical alterations. The aim of this study is to evaluate retrospectively the results of ERCP applications done in patients with Billroth II operation. METHODOLOGY: Out of the 1632 patients who underwent ERCP between 1992 and 2002, 27 (1.65%) had Billroth II operation. The records of these 27 patients were reviewed. Details noted included indications for ERCP, therapeutic interventions, causes of failure and complications. RESULTS: Out of the patients, 3 were female and 24 male (mean age 62+/-11). 26 patients had extrahepatic biliary obstruction. 1 patient had an external bile drain. The procedure was carried out 1-5 times (mean 1.5+/-1.1). Cannulation was achieved in 17 patients (62.96%). Out of the patients cannulated, 10 had choledocholithiasis, 4 malign choledochal stricture, 1 chronic pancreatitis, 1 bile leak and 1 periampullary tumor. Success rate of endoscopic treatment was 82.35% (14/17). Proximal migration of the stent and hemorrhage in gastric cardia were the complications observed in the distinct patients. CONCLUSIONS: ERCP procedure is quite an effective and safe method for diagnosis and treatment in patients with Billroth II anastomosis and extrahepatic cholestasis in spite of all difficulties.     

Endoscopic Papillary Large Balloon Dilation for the Retrieval of Bile Duct Stones After Prior Billroth II Gastrectomy

Background/Aims:

Endoscopic retrieval of large common bile duct (CBD) stones is often difficult in patients who have undergone Billroth II gastrectomy, as anatomic alterations may present technical barriers to successful cannulation and increase procedure-related complications. Endoscopic papillary large balloon dilation (EPLBD) can be an alternative technique for the removal of difficult stones. Accordingly, the aim of this study was to evaluate the safety and effectiveness of EPLBD for CBD stone extraction in patients with Billroth II gastrectomy.

Materials and Methods:

From July 2006 to November 2011, 30 patients who underwent EPLBD with limited endoscopic sphincterotomy (EPLBD + ES) or EPLBD alone for the treatment of large CBD stones (≥10 mm) after Billroth II gastrectomy were retrospectively reviewed. A large balloon dilator (12-18 mm) was used to dilate the ampullary orifice.

Results:

Selective cannulation was successful in 25 patients (83.3%) with a standard catheter. Of the 30 subjects, EPLBD + ES was performed in 19 and EPLBD alone in 11. The mean bile duct diameter was 17.7 ± 4.3 mm (range, 11-31 mm), and mean size of balloon dilation was 14.5 ± 2.6 mm (range, 12-18 mm). Stone removal was successfully completed in 29 patients (96.7%). Successful stone retrieval during the first session was achieved in 27 patients (90.0%). Two cases (6.7%) of mild pancreatitis responded to conservative treatment, and no perforation or mortality was encountered.

Conclusions:

EPLBD with or without needle knife (NK) sphincterotomy seems to be a safe and feasible modality for CBD stone retrieval in patients with prior Billroth II gastrectomy.     

Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy

Introduction

Roux-en-Y gastric bypass is increasingly performed in the United States. In addition, liver transplantation and other complex hepatobiliary surgeries are increasingly performed with creation of a Roux-en-Y hepaticojejunostomy. Consequently, endoscopists more frequently need to carry out endoscopic procedures in patients with Roux-en-Y anatomy.

Materials and methods

The present article discusses the techniques and instruments available to therapeutic endoscopists who are faced with the challenge of performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with long- or short-limb Roux-en-Y anatomy.

Conclusion

Endoscopists can successfully perform ERCP in patients with Roux-en-Y anatomy by making use of appropriate techniques and instruments.     

Sphincterotomy by triple lumen needle knife using guide wire in patients with Billroth Ⅱ gastrectomy

AIM:To investigate the usefulness of a guide wire and triple lumen needle knife for removing stones in BillrothⅡ(B-Ⅱ)gastrectomy patients.METHODS:Endoscopic sphincterotomy in patients with B-Ⅱgastrectomy is challenging.We used a new guide wire technique involving sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy.This technique was performed in nine patients between August 2010 and June 2012.Sphincterotomy as described above was performed.Adequate sphincterotomy,successful stone removal,and complications were investigated prospectively.RESULTS:Sphincterotomy by triple lumen needle knife using guide wire was successful in all nine patients.Sphincterotomy started towards the 4-5 o’clock direction and continued to the upper margin of the papillary roof.Complete stone removal in one session was achieved in all patients.There were no procedure related complications,such as bleeding,pancreatitis,or perforation.CONCLUSION:In patients with B-Ⅱgastrectomy,guide wire using sphincterotomy by triple lumen needle knife through a forward-viewing endoscopy seems to be an effective and safe procedure for the removal of common bile duct stones.     

ERCP在手术后胆漏中的诊治作用

目的探讨ERCP对肝胆术后胆漏诊断及治疗作用。方法对2003年1月至2008年12月接受ERCP诊治的120例肝胆术后胆漏患者进行回顾性分析。结果120例胆漏患者中,诊断肝外胆漏（Ⅰ型）71例、肝内胆管漏（Ⅱ型）39例、胆囊管漏（Ⅲ型）10例。其中76例行内镜下鼻胆管引流术（ENBD）,35例行胆管内支架引流术（ERBD）,3例行ERBD＋ENBD,2例单纯行经内镜乳头括约肌切开术（EST）,1例放置可回收金属支架行金属支架引流（EMBE）,3例内镜治疗失败。共完整随访98例,占81．7％（98／120）,其中有效治愈胆漏85例,有效治愈率为86．7％（85／98）,平均胆漏愈合时问为（18．2±7．0）d。各型胆漏中,Ⅲ型胆漏有效治愈率最高,为100．0％,且该型胆漏愈合时间最短,为（8．2±3．5）d;在Ⅰ型和Ⅱ型胆漏中,对应非肝移植术后胆漏有效治愈率明显高于肝移植术后（P〈0．01）,且愈合时间明显变短（P〈0．01）。结论ERCP是诊治肝胆术后胆漏的一种安全、有效的手段,具有重要的临床价值,可作为肝胆术后胆漏诊治的首选方法,对于Ⅲ型胆漏治疗效果尤佳。     

Endoscopic retrograde cholangiopancreatography in elderly patients.

BACKGROUND: the presentation of common bile duct disease, value of investigations and treatment outcome in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were assessed. METHODOLOGY: the clinical presentation, liver function tests, full blood counts, abdominal ultrasound and ERCP results were assessed retrospectively in 101 patients (59 women, 42 men; mean age 83 years, range 75-100) sequentially investigated for possible common bile duct disease. RESULTS: 59 patients had common bile duct gallstones, 35 had malignant biliary obstruction (13 with co-existing common bile duct stones) and seven had other outcomes. In the malignant-alone group 68% of those who had jaundice presented painlessly compared with 24% in the gallstones-alone group; 49% of the gallstones-alone group had pain compared with 28% of the malignant group. In the gallstones-alone group 43% had atypical presentations (non-specific symptoms or painless jaundice). Non-specific symptoms were found in 19% of the gallstones-alone group but in only 5% of the malignant group. Of the patients who had common bile duct stones, 18% had pancreatic or biliary malignancy. The co-existence of gallstones and malignancy was emphasized by eight patients in whom the clinical and ultrasound diagnosis was of common bile duct stones but malignancy was detected by ERCP. The sensitivity of ultrasound was 86% for detecting dilated common bile ducts was 86%, but only 69% for diagnosing gallstones within the common bile duct and 67% for diagnosing pancreatic masses. Ultrasound and ERCP were in agreement in 60 patients (60%). Endoscopic clearance of common bile duct gallstones was successful in 53 of 54 attempts (98%). Palliative ERCP treatment was performed in 30 patients who had malignant biliary obstruction and was successful in 22 (73%); in a further four patients (13%) an endoprothesis was successfully inserted percutaneously. The commonest complication of ERCP was cholangitis (four patients); pancreatitis and biliary perforation occurred in one patient each. Twenty-two patients (63%) who had malignancy died during follow-up, the mean survival being 11.3 weeks (range 3 days-2 years). Carcinoma of the ampulla was associated with a relatively good prognosis (three patients survived 18 months or more). CONCLUSION: in elderly patients, common bile duct stones often present atypically and co-existence with malignancy is not unusual; ampullary carcinoma has a relatively good prognosis and ERCP is a safe and effective procedure in the management of biliary obstruction.     

Endoscopic retrograde cholangiopancreatography in paediatric patients with biliary disorders

Endoscopic retrograde cholangiopancreatography (ERCP) has long been used in children. The usefulness of ERCP in paediatric patients with various biliary disorders, however, has not been well documented. Thirty-two sessions of ERCP performed in 29 paediatric patients ranging in age from 1 month to 15 years were evaluated. Endoscopic retrograde cholangiopancreatography was to confirm diagnosis or to obtain detailed information about their pancreaticobiliary system. Cannulation was successful in all patients. Opacification of the biliary tracts was also successful in all except for three patients with extrahepatic biliary atresia. Endoscopic retrograde cholangiopancreatography was assessed to be successful in making a differential diagnosis of neonatal hepatitis from extrahepatic biliary atresia, and in having a confirmed diagnosis of anomalous arrangement of the pancreaticobiliary ductal system associated with choledochal cyst. The procedure was also useful for obtaining detailed information on the pancreaticobiliary system in the other children. No accidents occurred during the endoscopic procedures in any of the paediatric patients. When a confirmed diagnosis or detailed information is needed in paediatric patients with biliary disorders, ERCP is a useful and safe technique.     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的探讨ERCP在治疗肝移植术后胆道并发症方面的作用。方法回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料。对25例胆道狭窄患者（吻合口狭窄14例,非吻合口狭窄11例）行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者（其中合并胆道狭窄8例）行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗。结果ERCP手术成功率为95．9％（94／98）,未出现严重并发症。吻合口狭窄的ERCP治愈率为100％（14／14）,非吻合口狭窄的ERCP治愈率为27．3％（3／11）,胆漏的ERCP治愈率为83．3％（5／6）,结道结石和胆泥形成患者的ERCP治愈率为81．3％（13／16）。结论ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低。     

Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed endoscopic retrograde cholangiopancreatography

Endoscopic ultrasonography （EUS）-guided biliary drainage was performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography （ERCP）. In the present study, we introduced the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients who failed in ERCR We performed the procedure in 2 papilla of Vater, including one resectable case, and 2 cases of cancer of the head of pancreas. Using a curved linear array echoendoscope, a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Using a biliary catheter for dilation, or papillary balloon dilator, a 7-Fr plastic stent was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. In 3 （75%） of 4 cases, an indwelling plastic stent was placed, and in one case in which the stent could not be advanced into the bile duct, a naso-biliary drainage tube was placed instead. In all cases, the obstructive jaundice rapidly improved after the procedure. Focal peritonitis and bleeding not requiring blood transfusion was seen in one case. In this case, pancreatoduodenectomy was performed and the surgical findings revealed severe adhesion around the choledochoduodenostomy site. Although further studies and development of devices are mandatory, EUS-guided choledochoduodenostomy appears to be an effective alternative to ERCP in selected cases.     

OBLIQUE‐VIEWING ENDOSCOPE FACILITATES ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATED PROCEDURES IN POST‐BILLROTH II GASTRECTOMY PATIENTS

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures have been reported to be difficult to perform in patients with Billroth II gastrectomy. We evaluated the feasibility of using an oblique‐viewing endoscope equipped with a cannula deflector for these procedures in such patients. Patients and Methods: Twenty‐four patients with Billroth II gastrectomy were enrolled in the present study and underwent ERCP, endoscopic sphincterotomy, endoscopic nasobiliary drainage, expandable metal stent placement or tube stent placement. All procedures were performed with an oblique‐viewing endoscope equipped with a cannula deflector. Results: In all patients, afferent loops were entered. Reaching the papilla of Vater was achieved in 22 (91.7%) patients, in whom all planned procedures were accomplished. One patient experienced acute pancreatitis, hemorrhage from the papilla of Vater after sphincterotomy, and intestinal perforation. Conclusions: We believe an oblique‐viewing endoscope equipped with a cannula deflector to be useful in performing ERCP and associated procedures in many patients with Billroth II gastrectomy. However, one should be aware of major complications, such as perforation, that may occur.