Gut, 1984, 25, 971-974

Liver and biliaryERCP and sphincterotomy after Billroth II gastrectomyA FORBES AND P B COTTON

From the Department of Gastroenterology, Middlesex Hospital, London

SUMMARY Endoscopic retrograde cholangiopancreatography (ERCP) procedures are moredifficult in patients who have undergone partial gastrectomy with Billroth II anastomosis. Resultsimprove with experience; we have achieved full diagnostic information in only 52% of 63attempts, but ultimately in 60% of the 53 patients concerned. Therapeutic endeavours were moresuccessful with useful results in eight of 10 patients during the last two years. Alternativediagnostic and therapeutic techniques should be used wherever possible in these patients.

Endoscopic retrograde cholangiopancreatography(ERCP) and its therapeutic developments havebecome popular in the management of patients withbiliary and pancreatic disease.' 2 Most failures arebecause of inexperience, but certain anatomicalarrangements may cause particular technicaldifficulty; these include congenital anomalies,duodenal stenosis, large peri-ampullary diverticula,and diversionary surgery, of which Billroth II partialgastrectomy is the most common. It may be difficultto enter the afferent loop selectively, and to reachand identify the papilla, particularly if the loop islong. Cannulation and sphincterotomy are moredifficult because of the direction of approach; forthis reason, some recommend the use of a forwardviewing endoscope3 (Fig. 1).We have reviewed our results of ERCP and

sphincterotomy in patients with Billroth IIanastomoses, in the light of encouraging reportsfrom other centres.8

Methods

PATI ENTSWe have reviewed a total of 4374 ERCP procedures,performed between 1971 and 1982. Approximatelytwo-thirds were performed by one of us (PBC), theremainder by other members of the department withvarying experience.

Sixty three attempts at ERCP had been made on53 patients who had previously undergone partialgastrectomy with Billroth II anastomosis. Theirmean age was 605 years (range 33-86 years).Endoscopic retrograde cholangiopancreatography

Address for correspondence: Dr A Forbes, Middlesex Hospital, MortimerStreet, London WIN 8AA.

Received for publication 2 November 1983

techniques have been described fully elsewhere.9Side viewing Olympus duodenoscopes were usedinitially in every case; slim and adult sized forwardviewing endoscopes were used subsequently in a fewpatients where difficulties were encountered.

Results

DIAGNOSTIC ERCPOver the whole series of 4374 patients, the successrate for cannulating the desired duct has been 86%(biliary) and 88% (pancreatic) (Table). Thesefigures have varied little over recent years; thebenefit of greater departmental experience has beenbalanced by the increasing proportion of proceduresperformed by trainees, and by the referral of manytechnically difficult problems.By contrast, selective cannulation and full

Fig. 1 (a) Normal anatomy with side viewingduodenoscope; (b) Billroth II anatomy with side viewingduodenoscope; (c) Billroth II anatomy with forwardviewing endoscope.

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rable 1 Selective cannulation success rates

Success rates (totals in parentheses)

OverallCannulation 1971-1982 1971-1979 1980-1982

All patients (per attempt) Biliary 86-7Cr (3510) 84 9% (1905) 88-9% (1605)Pancreatic 88-8%G (3168) 87-3% (1741) 90(6% (1427)

Billrothllonly(perattempt) Biliary 49-2%* (61) 35-5% (32) 62-1%* (29)Pancreatic 52.5%7* (61) 42-4% (33) 64-3%* (28)

Billroth 11only (per patient) Biliary 549%,/ -(51) 44-4% (27) 66-7%* (24)Pancreatic 60.4%* (53) 5f0'fi% (28) 72-0.%* (25)

* Include early 1983 figures.

diagnostic information was obtained at only 33(52%) attempts in patients with Billroth IIgastrectomy (Table). Failures were approximatelyequally because of inability to enter the afferentloop (eight occasions), to find the papilla (12occasions), and to cannulate despite identification ofthe papilla (10). Repeated attempts in some of thefailures yielded an eventual successful cannulationrate of 60% per patient. The increase in success ratefrom around 40% in the period 1971 to 1979, to over60% in the last three years (Table) is attributed toincreased experience; there have been no majorchanges in the types of instruments used, nor anyspecific technical modification. There were no com-plications from diagnostic ERCP in these patients.

THERAPEUTIC ERCPTherapeutic attempts have been made in only 10patients with a Billroth IL gastrectomy, all in the pasttwo years. During the same period, 392 otherpatients were submitted to endoscopic sphincter-otomy, with an overall success rate of 97%.

Useful results were eventually obtained in eight ofthe 10 patients with Billroth II gastrectomy. Onepatient with pain and a dilated bile duct aftercholecystectomy was treated by balloon dilatation ofthe papilla; he remains well at follow up at sixmonths. The second patient had a large bile ductstone and a spontaneous choledochoduodenal fistulaabove the papilla; the fistula was enlarged with adiathermy wire, and a Teflon prosthesis placed tosplint the stone. This patient remained well at followup at 14 months. Conventional sphincterotomy atthe papilla using a standard Olympus sphincter-otome was attempted in the remaining eightpatients, and succeeded in six; the duct was clearedof stones in four of these (Fig. 2). The fifth patientwas treated by placing a splinting Teflon prosthesisaround a large stone; he remains well at follow up at13 months. In the sixth patient with successfulsphincterotomy, attempts were made to dissolve a

2 5 cm diameter duct stone with mono-octanoininfused through a nasobiliary tube.'" There was noeffect after one week, and the patient underwentsurgery which was uneventful. Sphincterotomyinitially failed in two patients. In one case the

Fig. 2 Basket extraction ofcommon bile duct stone atERCP in patient with Billroth II anastomosis.

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ERCP and sphincterotomy after Billroth 11 gastrectomny

attempt was abandoned because it provedimpossible to insert the sphincterotome in thecorrect direction; this patient subsequently hadsuccessful surgery. In the second case, attempts toinvert the tip of the duodenoscope in the afferentloop to provide a better direction of approachresulted in perforation of the afferent loop; con-servative management was successful. The patientdeclined further treatment until developingcholangitis again after six months; on this occasion itwas possible to perform a sphincterotomy, and toplace a splinting prosthesis (Fig. 3). There were noother complications.

Discussion

Endoscopic retrograde cholangiopancreatographyand therapeutic procedures can be achieved inpatients who have previously undergone Billroth IIgastrectomy. Success rates of 55-88% per attempt atdiagnostic cannulation have been reported.3 7Where attempted, successful therapy has beenpossible in 66-100%,- but in only three ofSafrany's 23 successes was the first attempt com-

pletely successful, two patients needing four pro-cedures,' and Siegel's 100% record comprises 6nlyfour patients.7 Some experts prefer to use forwardviewing endoscopes, 3 specially designed cannulaeand sphincterotomes,> or novel techniques.6 Wehave achieved complete success in only 60% ofpatients (often only after considerable difficulty)and have not found that any special equipment ornovel technique has been particularly helpful.As ERCP is difficult in this context, we may

question when an attempt is really indicated.Endoscopy of the papilla and duodenal loop canprovide important diagnostic information particu-larly as radiography of the afferent loop is difficult.Endoscopic cholangiography and pancreatographyare nowadays less important for diagnosis becauseof the development and widespread availability ofother imaging techniques. Ultrasound and CTscanning (and recently ultrasound guided per-cutaneous pancreatography) reduce the need fordiagnostic pancreatography, and percutaneoustranshepatic cholangiography should provide gooddefinition of the biliary tree. Many groups preferendoscopic cholangiography because it is less

Fig. 3 (a) Large common bile duct stone in patient with Billroth 11 anastomosi.s; (b) biliarY endoprosthesissuccessfully placed arolund stone.

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974 Forbes and Cotton

traumatic, more likely to provide diagnostic chol-angiograms in patients without major obstructionand because it can lead on immediately to treat-ment, particularly in patients with stones. Therelative roles of endoscopic and percutaneousprostheses are still being explored. We can concludethat diagnostic ERCP can usually be avoided inpatients with Billroth II gastrectomy, the informa-tion being obtained by other techniques.The only remaining question is the role of

sphincterotomy in such patients. The success rate isconsiderably less than that achieved in patients withnormal anatomy. Results might improve with moreexperience, and perhaps with the development ofnew techniques. Occasionally it may be helpful tohave simultaneous percutaneous transhepatic assist-ance; sometimes it is justifiable to treat patients withlarge stones with an indwelling splinting prosthesis.In general, endoscopic therapy should be attemptedonly when there are major contraindications tosurgery.

We should like to thank the many surgeons andphysicians who have referred patients to us.

References

1 Cotton PB. Progress report: ERCP. Gut 1977; 18:316-41.

2 Cotton PB, Vallon AG. British experience withduodenoscopic sphincterotomy for treatment of bileduct stones. Br J Surg 1981; 68: 373-5.

3 Katon RM, Bilbao MK, Parent JA, Smith FW. ERCPin patients with gastrectomy and gastrojejunostomy(Billroth II). Gastrointest Endoscopy 1975; 21: 164-5.

4 Safrany L. Endoscopy and retrograde cholangio-pancreatography after Billroth II operation.Endoscopy 1972; 4: 198-202.

5 Safrany L, Neuhaus B, Portocarrero G, Krause S.Endoscopic sphincterotomy in patients with Billroth IIgastrectomy. Endoscopy 1980; 12: 16-22.

6 Rosseland AR, Osnes M, Kruse A. Endoscopicsphincterotomy in patients with Billroth IIgastrectomy. Endoscopy 1981; 13: 19-24.

7 Siegel JH, Yatoo RP. ERCP and endoscopicpapillotomy in patients with a Billroth II gastrectomy;report of a method. Gastrointest Endosc 1983; 29:116-8.

8 Thon HJ, Loffer A, Buess G, Gheorghiu Th. Is ERCPa reasonable diagnostic method for excludingpancreatic and hepatobiliary disease in patients with aBillroth II resection? Endoscopy 1983; 15: 93-5.

9 Cotton PB, Williams CB. In: Practical gastrointestinalendoscopy 2nd ed. Oxford: Blackwell, 1982.

10 Jarrett LN, Balfour TW, Bell GD, Knapp DR, RoseDH. Intraductal infusion of Mono-octanoin; experi-ence in 24 patients with retained common bile ductstones. Lancet 1981; 1: 68-70.

1 1 Cremer M, Gulbis A, Toussaint J, deToeuf J,Vanlaethem A, Hermanus A. Techniques of endo-scopic papillotomy. In: Delmont J, ed. The sphincter ofOddi. Basel: Karger, 1977.

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