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

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.

Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy. METHODS: The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope. RESULTS: The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths. CONCLUSIONS: Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.

Usefulness of Forward-Viewing Endoscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II Gastrectomy

BACKGROUND/AIMS: Patients undergoing Billroth II (B II) gastrectomy are at higher risk of perforation during endoscopic retrograde cholangiopancreatography (ERCP). We assessed the success rate and safety of forward-viewing endoscopic biliary intervention in patients with B II gastrectomy. METHODS: A total of 2,280 ERCP procedures were performed in our institution between October 2008 and June 2011. Of these, forward-viewing endoscopic biliary intervention was performed in 46 patients (38 men and 8 women with B II gastrectomy). Wire-guided selective cannulations of the common bile duct using a standard catheter and guide wire were performed in all patients. RESULTS: The success rate of afferent loop entrance was 42 out of 46 patients (91.3%) and of biliary cannulation after the approach of the papilla was 42 out of 42 patients (100%). No serious complications were encountered, except for one case of small perforation due to endoscopic sphincterotomy site injury. CONCLUSIONS: When a biliary endoscopist has less experience and patient volume is low, ERCP with a forward-viewing endoscope is preferred because of its ease and safety in all patients with prior B II gastrectomies. Also, forward-viewing endoscope can be used to improve the success rate of biliary intervention in B II patients.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

BACKGROUND/AIMS: Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy. METHODS: Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications. RESULTS: Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred. CONCLUSIONS: Without preceding sphincterotomy, one-step EPBD (> or =10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (> or =10 mm) with CBD dilatation in Billroth II gastrectomy.

Endoscopic Papillary Large Balloon Dilation Combined with Guidewire-Assisted Precut Papillotomy for the Treatment of Choledocholithiasis in Patients with Billroth II Gastrectomy

BACKGROUND/AIMS: Endoscopic extraction of bile duct stones is difficult and often complicated in patients with a Billroth II gastrectomy. We evaluated a simpler technique to achieve an adequate ampullary opening for the removal of choledocholithiasis using endoscopic papillary large balloon dilation (EPLBD) combined with a guidewire-assisted needle-knife papillotomy. METHODS: Sixteen patients who had a Billroth II gastrectomy were included in this study. Following placement of the guidewire in the bile duct, a precut incision was made over the guidewire with a needle knife sphincterotome inserted alongside the guidewire. Balloon dilation of the ampullary orifice was gradually performed. RESULTS: Needle knife papillotomy over the guidewire with subsequent EPLBD was successful in all patients. Complete stone removal was achieved in 15 (93.7%) patients in 1 session. However, 1 (6.3%) patient required mechanical lithotripsy with an additional procedure for complete ductal clearance, and there was 1 case of minor bleeding following the EPLBD. There were no cases of pancreatitis or perforation. CONCLUSIONS: EPLBD followed by guidewire-assisted needle-knife papillotomy appears to be a useful method with few technical difficulties and a low risk of complications for the removal of bile duct stones in patients with prior Billroth II gastrectomy.

A Case of Afferent Loop Syndrome Treated by Endoscopic Drainage Procedure using Nasogastric Tube / 대한소화기학회지

Afferent loop syndrome is an uncommon complication which occurs in patients with Billroth II partial gastrectomy. Clinically, the diagnosis of afferent loop syndrome may be difficult to establish and thus, depends on the finding of computed tomography, abdominal ultrasound, barium studies and hepatobiliary scan. When the diagnosis is made, most of the cases are treated by surgical operation. We present a case of 67-year-old male patient with afferent loop syndrome associated with acute pancreatitis which was treated by endoscopic drainage procedure using a nasogastric tube.

Comparison of the Early Postoperative Results after a Billroth I and a Billroth II Gastrectomy for Gastric Cancer

PURPOSE: The proper reconstructive technique after a partial gastrectomy for an adenocarcinoma of the stomach is often debated, but few data exist to clarify the issue. The aim of this study was to compare retrospectively the early postoperative results and complications after different anastomoses used during a partial gastrectomy for a gastric adenocarcinoma. MATENRIALS AND METHODS: We reviewed the hospital records of 218 patients who had undergone a subtotal gastrectomy for gastric cancer at Chosun University Hospital between January 1997 and July 2000. Of the 218 subtotal gastrectomies performed with curative intent, 127 reconstructions were Billroth I gastrectomies and 91 were Billroth II gastrectomies. The following data were analyzed: age, sex, tumor size, gastric resection margin, timing of removal of the nasogastric tube, first bowel movement, resumption of oral feeding, and postoperative complications. RESULTS: The timing of removal of the nasogastric tube was significantly earlier in the Billroth Igroup than in the Billroth II group (27.9+/-13.9 hours and 69.7+/-68 hours, respectively)(P<0.05). Resumption of oral feeding was possible on day 4.6+/-1.5 in the Billroth I group and on dsy 5.2+/-1.5 in the Billroth II group (P<0.05). There were no anastomotic leakage, postoperative bleeding, and postoperative mortality among the patients in either group. CONCLUSION: the Billroth Igastrectomy should be considered for patients undergoing a partial gastric resection for gastric cancer due to its physiological benefits and acceptable rate of complication.

A Stent-Guided Sphincterotomy in Patients with a Difficult Periampullary Diverticulum or with a Billroth-II Gastrectomy / 대한소화기내시경학회지

BACKGROUND/AIMS: Patients with a congenitally or surgically altered anatomy such as a large diverticulum in which an ampullary orifice exists or a Billroth-II gastrectomy, have an increased complication rate after endoscopic sphincterotomy (EST) compared to normal anatomies. An experience involving a stent-guided sphincterotomy using an endoprosthesis is herein reported. METHODS: 10 patients with a Billroth-II gastrectomy and 9 patients with a large diverticulum received a stent-guided EST. In the diverticula cases, all the ampullary orifices were located either inside the diverticulum or in an unusual position. All patients had common bile duct stones and symptoms of cholangitis. After a 0.035 inch guide wire was inserted through the side-viewing duodenoscope, a 10 Fr. endoprosthesis (MTW, Germany) was inserted and a needle-knife sphincterotome was introduced. In patients with a Billroth-II anatomy, the incision was made from the papillary orifice of the 12 o'clock position toward 6 o'clock. In patients with periampullary diverticula, the incision was made with sweeps of the needle-knife in a 6 to 12 o'clock direction. The cautery current was applied to the mucosa along the stent and the stent was retrieved by a polypectomy snare through the biopsy channel without removal of an endoscope. RESULTS: Among the 19 patients, the guide wire and stent insertion were possible in all except one patient due to the inability of selective cannulation. An EST was performed in all patients after stent insertion. There were no serious complications during and after the stent-guided EST except for two minor bleedings which were treated with a coagulation current using the needle-knife. Consequently, complete endoscopic stone removal was achieved in all patients including three patients in whom a mechanical lithotriptor was needed. CONCLUSIONS: In stent-guided EST, the stent not only guides the adequate direction of the incision but also allows a controlled incision under a favorable visual field. Therefore, blind cutting and exploration during EST can be avoided and successful EST is possible even in difficult situations such as that created by an altered anatomy.

Therapeutic Endoscopic Retrograde Cholangiography in Patients with a Billroth II Gastrectomy: 2 cases of ERBD & 1 case of endoscopic stone retrievial / 대한소화기내시경학회지

Endoscopic retrograde cholangiopancreatography(ERCP) procedures are more difficult in patients who have undergone partial gastrectomy with Billroth II anastomosis. Because its altered anatomical relationship. the endoscopist is presented with additional problems: (i) Dfficulties in entering the afferent loop, depending on the surgical techiques used. (ii) The endoscope may be too sort to reach the papillary region unless the loops are suecessfully straightened out. (iii) Difficulties in passing the ligament of Treitz, especially in patients with Braun's anastomosis, (iv) Problems in cannulating the papilla and especially the common bile duct from a reversed position. (v) Problems in carrying out a papillotomy in a correct position. We attempted endoscopic sphincterotomy in 3 opatients previously subjected to gastrectomy with needle knife, and succeeded in 2 of them. In the two patients, successful billary drainage was achieved. And one patients with Billroth II gastrectomy, presented with CBD stone and cholangit, was successfully treated with endoscopic stone retriveial. The patient with a Billroth-II operation may unergo endscopic diagnostic as well as therapeutic procedures with a high rate of success, and can be suitable candidates for ERCP and endoscopic sphincterotomy