Background and study aim: Endoscopic retrograde cholangiopancreatography (ERCP) is difficult in patients with
altered anatomy following Billroth II gastrectomy. Afferent loop intubation, selective
cannulation, and sphincterotomy are the main issues. Experience from a tertiary referral
endoscopy center is reported.
Patients and methods: A total of 713 patients with Billroth II reconstruction who underwent ERCP between
October 1982 and October 2012 were retrospectively identified from a prospectively
collected database (mean age 69 ± 27 years; 567 males). The main indications for ERCP
were common bile duct stones (51.2 %) and obstructive jaundice (24.8 %). Procedures
were always started with a duodenoscope; in cases of failure to reach the papilla
the duodenoscope was changed to a gastroscope. Endoscopic sphincterotomy was performed
using a long-nose sigmoid inverted sphincterotome.
Results: The successful duodenal intubation rate was 86.7 % (618/713 patients). The main reason
for intubation failure was a long and angulated afferent loop. Successful cannulation/opacification
of the desired biliopancreatic duct was 93.8 % (580/618). Biliary and/or pancreatic
sphincterotomy were performed in 490 (84.5 %) and 23 (4.0 %) patients, respectively.
The adverse event rate was 4.3 % (45/1050 procedures). Peritoneal perforation occurred
in 1.8 % of the cases (19/1050 procedures) and always required immediate surgery.
Two patients died after surgery (overall mortality 0.3 %). The other adverse events
resolved following conservative management or endoscopic reintervention.
Conclusions: In experienced centers, ERCP in Billroth II patients had morbidity and mortality
rates that were comparable to patients with normal anatomy. The main reasons for failure
were related to the inability to reach the papilla. Peritoneal perforation was the
most common adverse event, and required a prompt surgical approach.
