Endoscopic Retrograde Cholangiopancreatography Using a Dual-Lumen Endogastroscope for Patients with Billroth II Gastrectomy. Gastroenterol Res Pract. 2013;2013:146867. [PMID: 23781239 PMCID: PMC3678468 DOI: 10.1155/2013/146867]

Side-Viewing Duodenoscope versus Forward-Viewing Gastroscope for Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is still a challenging procedure. The optimal approach, namely the type of endoscope and sphincter management, has yet to be defined.

Aim

To compare the efficacy and safety of forward-viewing gastroscope and the side-viewing duodenoscope in ERCP of patients with Billroth II gastrectomy.

Methods

We conducted a retrospective, single-center cohort study of consecutive patients with Billroth II gastrectomy submitted to ERCP in an expert center for ERCP between 2005 and 2021. The outcomes assessed were: papilla identification, deep biliary cannulation, and adverse events (AEs). Multivariate analysis was performed to evaluate potential associations and predictors of the main outcomes.

Results

We included 83 patients with a median age of 73 (IQR 65-81) years. ERCP was performed using side-viewing duodenoscope in 52 and forward-viewing gastroscope in 31 patients. Patients' characteristics were similar in the two groups. The global rate of papilla identification was 66% (n = 55). The rate of deep cannulation was 58% considering all patients and 87% in the subgroup of patients in which the papilla major was identified. Cannulation was performed with standard methods in 65% of cases and with needle-knife fistulotomy in 35%. AEs occurred in 4 patients. There was no difference between duodenoscope and gastroscope in papilla identification (64% [95% CI: 51-77] vs. 71% [55-87]). Although not statistically significant, duodenoscope had a lower deep cannulation rate when considering all patients (52% [15-39] vs. 68% [7-35]) and a higher AEs rate (8% [1-15] vs. 0% [0-1]). In a multivariate analysis, the use of gastroscope significantly increased the deep cannulation rate (OR = 152.62 [2.5-9,283.6]).

Conclusion

This study demonstrates that forward-viewing gastroscope is at least as effective and safe as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Moreover, our study showed that gastroscope is an independent predictor of successful cannulation.

Challenges of endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrointestinal anatomy: A review article

Endoscopic retrograde cholangiopancreatography (ERCP) is a combination of endoscopy and fluoroscopy that is commonly used in the management of pancreatobiliary diseases. ERCP can be challenging if performed in surgically altered anatomy, such as a Billroth II reconstruction, compared with native anatomy and usually has a lower success rate. We identified five emerging challenges in such patients. These are the choice of endoscope, the identification of afferent loop, reaching the duodenal stump, cannulation in the reverse position, and endoscopic sphincterotomy. Performing ERCP in patients with a Billroth II reconstruction needs adequate knowledge, proper skill, and experience to achieve a good clinical outcome.

Recent advances in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: A systematic review

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy. However, there has been a paucity of comparative studies regarding ERCP in Billroth II gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations. This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth II gastrectomy patients.

AIM

To systematically review the literature regarding ERCP in Billroth II gastrectomy patients.

METHODS

A systematic review was performed on the literature published between May 1975 and January 2019. The following electronic databases were searched: PubMed, EMBASE, and Cochrane Library. The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed.

RESULTS

A total of 43 studies involving 2669 patients were included. The study designs were 36 (83.7%) retrospective cohort studies, 4 (9.3%) retrospective comparative studies, 2 (4.7%) prospective comparative studies, and 1 (2.3%) prospective cohort study. Of a total of 2669 patients, there were 1432 cases (55.6%) of side-viewing endoscopy, 664 (25.8%) cases of forward-viewing endoscopy, 171 (6.6%) cases of balloon-assisted enteroscopy, 169 (6.6%) cases of anterior oblique-viewing endoscopy, 64 (2.5%) cases of dual-lumen endoscopy, 31 (1.2%) cases of colonoscopy, and 14 (0.5%) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91.3% (2437/2669), and the overall success rate of selective cannulation was 87.9% (2346/2437). A total of 195 cases (7.3%) of adverse events occurred. The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows: side-viewing endoscopy 98.2% and 95.3%; forward-viewing endoscopy 97.4% and 95.2%; balloon-assisted enteroscopy 95.4% and 97.5%; oblique-viewing endoscopy 94.1% and 97.5%; and dual-lumen endoscopy 82.8% and 100%, respectively. The rate of bowel perforation was slightly higher in side-viewing endoscopy (3.6%) and balloon-assisted enteroscopy (4.1%) compared with forward-viewing endoscopy (1.7%) and anterior oblique-viewing endoscopy (1.2%). Mortality only occurred in side-viewing endoscopy (n = 9, 0.6%).

CONCLUSION

The performance of ERCP in the Billroth II gastrectomy population has been improving with choice of various type of endoscope and sphincter management. More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth II gastrectomy patients.

[Comparison of the minimally invasive treatments of laparoscopic and endosopic for common bile duct stones after gastrojejunostomy]

OBJECTIVE

To explore the feasibility and to compare the merits and demerits of laparoscopic and endoscopic approach in removing common bile duct stones in patients with gastrojejunostomy after gastrectomy.

METHODS

Between January 2012 and December 2016, 25 patients with common bile duct stones after gastrojejunostomy received laparoscopic or endoscopic treatment in our centers. They were divided into laparoscopic group and endoscopic group based on treatment approaches for common bile duct stones, including 15 patients in laparoscopic group and 10 in endoscopic group. The clinical characteristics and outcomes between the two groups were retrospectively analyzed.

RESULTS

Among the 25 patients with gastrojejunostomy, the method of reconstruction was Billroth II in 21 patients and Roux-en-Y in 4 patients. Six patients received laparoscopic or endoscopic treatment during the acute cholangitis state. Among the laparoscopic group, 5 patients with stones more than 1 cm, 7 patients with multiple stones, while in the endoscopic group, 3 patients with stones more than 1 cm and 4 patients with multiple stones. Fourteen patients in the laparoscopic group with coexisting gallbladder stones, and 6 of their common bile duct stones were successfully removed by transcystic approach without T tube drainage. Stone removals were successful in 4 patients of the endoscopic group by a single performance, including 3 patients with single small stone and one patient with multiple small stones. Two patients in the laparoscopic group were converted to open surgery for severe adhesion and one patient in the endoscopic group turned to laparoscopic operation for failing of finding papilla in the Roux-en-Y anastomotic status. The median hospital stays were 12 d and 10 d, respectively in the laparoscopic and endoscopic group. There were 3 patients with postoperative complications, including one patient with paralytic ileus in the laparoscopic group and 2 patients with biliary pancreatitis or bacteremia in the endoscopic group, and all of them recovered uneventfully with conservative treatment.

CONCLUSION

Both laparoscopic and endoscopic approaches are feasible for removing stones in the common bile duct in patients with gastrojejunostomy after gastrectomy, and they complement each other. In addition, both techniques are difficult to conduct, and a technical competence should be considered in selection of each method.

Forward-viewing endoscope for ERCP in patients with Billroth II gastrectomy: a systematic review and meta-analysis

BACKGROUND

The forward-viewing endoscope has been increasingly used to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent Billroth II gastrectomy. This study intended to assess efficacy and safety of the forward-viewing endoscope for ERCP in Billroth II gastrectomy patients compared with conventional side-viewing endoscope using a systematic review and meta-analysis.

METHODS

A systematic review was conducted for studies that evaluated the outcomes of ERCP for patients with Billroth II gastrectomy. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for non-randomized studies. The publication bias was assessed.

RESULTS

In total, 25 studies (1 randomized, 18 retrospective, 1 prospective, and 5 case series studies) with 2446 patients (499 forward-viewing and 1947 side-viewing endoscopes) were analyzed. The pooled afferent loop intubation rate was higher with the forward-viewing endoscope (90.3%, 95% confidence interval (CI) 85.6-93.6 vs. 86.8%, 95% CI 82.8-89.9%). The pooled selective cannulation rate was higher with the side-viewing endoscope (92.3%, 95% CI 88.0-95.2 vs. 91.1%, 95% CI 87.2-93.9%). The pooled bowel perforation rate was higher with the side-viewing endoscope (3.6%, 95% CI 2.3-5.7 vs. 3.0%, 95% CI 1.7-5.3%). The pooled pancreatitis rate was higher with the forward-viewing endoscope (5.4%, 95% CI 3.6-8.0 vs. 2.5%, 95% CI 2.3-5.7%). The pooled bleeding rate was higher with the forward-viewing endoscope (3.0%, 95% CI 1.6-5.5 vs. 2.0%, 95% CI 1.4-3.0%). The heterogeneity among the studies was not significant. The publication bias was minimal.

CONCLUSION

This meta-analysis indicates that the forward-viewing endoscope is as safe and effective as conventional side-viewing endoscope for ERCP in patients with Billroth II gastrectomy.

Comparison between double-guidewire technique and transpancreatic sphincterotomy technique for difficult biliary cannulation

BACKGROUND AND AIM

The aim of the present study was to compare the effectiveness and complications of the double-guidewire technique (DWT) with the transpancreatic sphincterotomy (TPS) technique.

METHODS

From January 2013 to December 2014, 366 consecutive endoscopic retrograde cholangiopancreatography (ERCP) procedures were carried out. Of 366 procedures, 354 procedures were carried out in patients with native major papilla biliary cannulation. A total of 279 consecutive therapeutic ERCP were included in the study and data of included patients were collected retrospectively. One hundred and thirty-seven procedures (49.1%) were done with DWT and 142 procedures (50.9%) were done with TPS for patients with difficult cannulation. The results and complications of ERCP were compared.

RESULTS

Success rate of first-attempt cannulation was 62.0% in the DWT group and 81.0% in the TPS group (P = 0.00). Final rate of successful cannulation of the two biliary cannulation techniques was 86.9% and 90.8%, respectively (P = 0.09). Cannulation time in the DWT group was 7.8 ± 1.7 min compared with 3.7 ± 2.3 min in the TPS group (P = 0.00). Overall incidence of post-ERCP pancreatitis (PEP), hemorrhage, perforation and cholangitis was 1.8%, 1.1%, 0.4% and 1.1%, respectively. Adverse event rate was 2.19% in the DWT group and 7.04% in the TPS group (P = 0.04).

CONCLUSIONS

DWT and TPS procedures were safe and effective. Overall cannulation rate was similar between the groups. Although DWT had a longer cannulation time, it could be considered the preferred technique in patients with failed standard cannulation for lower adverse event rate.

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.