Cap-assisted ERCP in patients with a Billroth II gastrectomy

BACKGROUND: ERCP is difficult in patients with a Billroth II gastrectomy because of anatomical changes. OBJECTIVE: Cap-assisted ERCP can improve the cannulation rate and the success rate of stone removal. DESIGN: Case series. SETTING: A tertiary referral center. PATIENTS AND INTERVENTIONS: Ten consecutive patients with bile-duct stones (9) or a distal common bile duct stricture (1), who had previously undergone Billroth II gastrectomy and were referred for ERCP, were analyzed for the outcome of their ERCP. All procedures were carried out with a cap-fitted regular forward-viewing endoscope. MAIN OUTCOME MEASUREMENTS: Ability to perform afferent loop intubation and bile-duct cannulation. RESULTS: Of 10 patients in whom ERCP was attempted, afferent loop intubation and selective bile-duct cannulation were achieved in all patients (100%). Endoscopic sphincterotomy (EST) was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and endoscopic papillary balloon dilation in 2 patients. There were no serious complications in the patients. LIMITATIONS: Small sample size, single-center experience. CONCLUSIONS: Diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted endoscope.