Endoscopic Access to the Papilla of Vater for Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II or Roux-en-Y Gastrojejunostomy

Abstract

Background and Study Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is an established modality for the diagnosis and treatment of pancreaticobiliary disorders. In contrast to ERCP in patients who have not undergone gastrectomy, ERCP in patients with a Billroth II gastrojejunostomy or a Roux-en-Y anastomosis is considerably more difficult. It was nevertheless considered that ERCP might be possible in most patients with gastrectomies, and this hypothesis was tested.

Patients and Methods: A total of 2256 patients were admitted to our hospital for ERCP from 1990 to 1994. Of these, 65 (3 %) had gastrojejunostomies, either with Billroth II reconstructions or with the Roux-en-Y procedure. ERCP was always performed with a conventional side-viewing endoscope.

Results: We examined the 65 patients with gastrojejunostomies. Of these, 91 % had Billroth II anastomoses and 9 % had received Roux-en-Y reconstructions. We successfully reached the papilla of Vater with the endoscope in 92 % of the patients with Billroth II gastrojejunostomies (54 of 59), but in only 33 % of the patients with Roux-en-Y reconstructions (two of six). In 8 % of the cases of Billroth II anastomosis, it was not possible to advance the endoscope into the duodenal stump, due to intestinal stenoses (5 %) or excessive intestinal length (3 %). Failure in case of regular Billroth II anatomy occured only in patients who had not received Braun enteroenterostomies. Failure also occured in 67 % of the Roux-en-Y gastrojejunostomy cases due to excessive intestinal length.

Conclusions: Most patients with Billroth II gastrojejunostomy (92 % of those in the present study) and some patients with Roux-en-Y anastomosis (33 % of those in the present study) can be investigated by ERCP and endoscopically treated in cases of pancreaticobiliary disorder. Braun enteroenterostomy has no negative impact on the endoscopic access to the papilla of Vater in patients with Billroth II gastrojejunostomy. Surgical reconstruction of the gastrointestinal tract to perform gastrojejunostomy should also take endoscopic requirements into account. In view of both the potential postoperative complications and endoscopic requirements, the jejunojejunostomy should be placed nearer to the gastrojejunostomy than 60 cm, and the afferent loop should be as short as possible.