Transhepatic balloon sphincteroplasty for bile duct stones after total gastrectomy

Papillary balloon dilation is not itself a cause of post-endoscopic retrograde cholangiopancreatography pancreatitis; results of anterograde and retrograde papillary balloon dilation

OBJECTIVES

The mechanism of pancreatitis development following endoscopic papillary balloon dilation (EPBD) remains unknown. Antegrade dilation with percutaneous transhepatic papillary balloon dilation (PTPBD) allows the removal of bile duct stones or fragments during percutaneous choledochoscopic lithotomy, with less mechanical trauma to the papilla than with EPBD-mediated stone removal.

METHODS

A total of 56 patients with bile duct stones underwent antegrade dilation with PTPBD from March 2006 to February 2011. A total of 208 patients with common bile duct stones underwent retrograde dilation with EPBD during the same period. The conditions of papillary balloon dilation were identical in both groups. The frequencies of pancreatitis and hyperamylasemia were compared in both groups.

RESULTS

Pancreatitis occurred in 14 (6.7%) of 208 patients in the EPBD group (mild, nine; moderate, four; severe, one). There was no case of pancreatitis among 56 patients in the PTPBD group (P < 0.05). Hyperamylasemia developed in significantly more patients treated in the EPBD group (62, 29.8%) compared with the PTPBD group (4, 7.1%; P < 0.05). Complete bile duct clearance was achieved in 98.2% of PTPBD group and 97.1% of EPBD group.

CONCLUSIONS

The rates of post-procedural pancreatitis and hyperamylasemia were significantly higher after retrograde dilation with EPBD than after antegrade dilation with PTPBD for the removal of bile duct stones. Although the mechanism of pancreatitis following papillary balloon dilation remains unclear, post-EPBD pancreatitis may be associated with procedures before and after balloon dilation similar to mechanical lithotripsy rather than balloon dilation itself.

A possible variant of Bouveret's syndrome presenting as a duodenal stump obstruction by a gallstone after Roux-en-Y gastrectomy: a case report

Introduction

Bouveret's syndrome is characterized by gastric outlet obstruction due to a gallstone in the duodenum, usually in association with a cholecystoduodenal fistula.

Case presentation

We report the case of a 69-year-old Caucasian man who developed duodenal stump obstruction due to an impacted gallstone after having previously undergone Roux-en-Y gastrectomy.

Conclusions

Duodenal stump obstruction after Roux-en-Y gastrectomy is rare, and may be difficult to manage. Patients who present with upper gastrointestinal or pancreatobiliary pathology after previous gastric surgery should be managed in centres with the availability of appropriate endoscopic and surgical experience.