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

The Success and Safety of Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Gastrointestinal Anatomy

BACKGROUND/OBJECTIVES

Performing endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered gastrointestinal anatomy remains challenging, frequently necessitating the use of forward-viewing endoscopes. Given the challenge in endoscope selection based on the type of altered anatomy, the aim of this study was to examine ERCP success rates by specific endoscopes for different anatomy types.

METHODS

This single-center retrospective study examined ERCPs performed in patients with surgically altered gastrointestinal anatomy during an 18-year period. Enteroscopy success, cannulation success, and intervention success rates were compared between the different anatomy and endoscope types.

RESULTS

This study included a total of 334 adult patients (665 total ERCPs) with altered anatomy. The pediatric colonoscope was most frequently utilized (32.2%), and the majority of procedures were performed for biliary indications. Enteroscopy success was 82.2% in Roux-en-Y gastric bypass (RYGB), 97% in Billroth II, 91.5% in Whipple, and 93.2% in Roux-en-Y hepaticojejunostomy (RYHJ). Cannulation success was 90.5% in RYGB, 90.5% in Billroth II, 83.6% in Whipple, and 90.6% in RYHJ. Intervention success was 88.2% in Billroth II, 65.1% in RYGB, 81.6% in Whipple, and 87.5% in RYHJ. In patients with RYGB and RYHJ, SBE was utilized most frequently, with rotational enteroscopy having the highest success rates. The overall adverse event rate was 5.1%, with the majority of these being mild in severity.

CONCLUSIONS

This large retrospective study found ERCP with forward-viewing endoscopes to be safe and effective for a variety of surgically altered anatomy types. Despite recent advances seen with endoscopic ultrasound-guided drainage procedures, this study advocates for ERCP as the initial approach for pancreaticobiliary access in surgically altered anatomy.

Motor-free telerobotic endomicroscopy for steerable and programmable imaging in complex curved and localized areas

Intraluminal epithelial abnormalities, potential precursors to significant conditions like cancer, necessitate early detection for improved prognosis. We present a motor-free telerobotic optical coherence tomography (OCT) endoscope that offers high-resolution intraluminal imaging and overcomes the limitations of traditional systems in navigating curved lumens. This system incorporates a compact magnetic rotor with a rotatable diametrically magnetized cylinder permanent magnet (RDPM) and a reflector, effectively mitigating thermal and electrical risks by utilizing an external magnetic field to maintain temperature increases below 0.5 °C and generated voltage under 0.02 mV. Additionally, a learning-based method corrects imaging distortions resulting from nonuniform rotational speeds. Demonstrating superior maneuverability, the device achieves steerable angles up to 110° and operates effectively in vivo, providing distortion-free 3D programmable imaging in mouse colons. This advancement represents a significant step towards guidewire-independent endomicroscopy, enhancing both safety and potential patient outcomes.

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.

Optimal choice of stapler and digestive tract reconstruction method after distal gastrectomy for gastric cancer: A prospective case-control study

BACKGROUND

Gastric cancer is the most common cause of cancer-related deaths, and is classified according to its location in the proximal, middle, or distal stomach. Surgical resection is the primary approach for treating gastric cancer. This prospective study aimed to determine the best reconstruction method after distal gastrectomy for gastric cancer.

AIM

To explore the efficacy of different staplers and digestive tract reconstruction (DTR) methods after radical gastrectomy and their influence on prognosis.

METHODS

Eighty-seven patients who underwent radical gastrectomy for distal gastric cancer at our institution between April 2017 and April 2020 were included in this study, with a follow-up period of 12-26 mo. The patients were assigned to four groups based on the stapler and DTR plan as follows: Billroth Ⅰ (B-I) reconstruction + linear stapler group (group A, 22 cases), B-I reconstruction + circular stapler group (group B, 22 cases), Billroth II (B-II) reconstruction + linear stapler group (group C, 22 cases), and B-II reconstruction + circular stapler group (group D, 21 cases). The pathological parameters, postoperative gastrointestinal function recovery, postoperative complications, and quality of life (QOL) were compared among the four groups.

RESULTS

No significant differences in the maximum diameter of the gastric tumors, total number of lymph nodes dissected, drainage tube removal time, QLQ (QOL questionnaire)-C30 and QLQ-STO22 scores at 1 year postoperatively, and incidence of complications were observed among the four groups (P > 0.05). However, groups A and C (linear stapler) had significantly lower intraoperative blood loss and significantly shorter anastomosis time, operation time, first fluid diet intake time, first exhaust time, and length of postoperative hospital stay (P < 0.05) than groups B and D (circular stapler).

CONCLUSION

Linear staplers offer several advantages for postoperative recovery. B-I and B-II reconstruction methods had similar effects on QOL. The optimal solution can be selected according to individual conditions and postoperative convenience.

Endoscopic ultrasound guided access procedures following surgery

EUS-guided therapeutic procedures have emerged in the recent years as a minimally invasive option for the management of complex hepatobiliary disorders. Gastrointestinal surgeries, e.g., pancreaticoduodenectomy, Roux-en-Y Gastric Bypass, Roux-en-Y hepaticojejunostomy, and partial gastrectomy with different reconstructions are commonly performed for a wide range of indications that include tumour resections and weight loss. Conventional endoscopic procedures are challenging in those patients due to inaccessible or unreachable ampulla. Patients with surgically altered anatomy are good candidates for EUS-guided access procedures that have shown good technical and clinical success rates. This category of procedures includes EUS-guided biliary drainage, EUS-guided pancreatic drainage, EUS-directed transgastric ERCP (EDGE) and EUS-guided Gastroenterostomy. Studies have shown that these procedures have comparable or better results than traditional endoscopic, interventional radiology-guided and surgical procedures. This article discusses the indications, technique and outcome of the different EUS-guided access procedures in patients with surgically altered anatomy.

Does the addition of Braun anastomosis to Billroth II reconstruction on laparoscopic-assisted distal gastrectomy benefit patients?

BACKGROUND

Operation is the primary therapeutic option for patients with distal gastrectomy. Braun anastomosis is usually performed after Billroth II reconstruction, which is wildly applied on distal gastrectomy because it is believed to benefit patients. However, studies are needed to confirm that.

AIM

To identify whether the addition of Braun anastomosis to Billroth II reconstruction on laparoscopy-assisted distal gastrectomy benefits patients.

METHODS

A total of 143 patients with gastric cancer underwent laparoscopy-assisted distal gastrectomy at Centre 1 of PLA general hospital between January 2015 and December 2019. Clinical data of the patients were collected, and 93 of the 143 patients were followed up. These 93 patients were divided into two groups: Group 1 (Billroth II reconstruction, 33 patients); and Group 2 (Billroth II reconstruction combined with Braun anastomosis, 60 patients). Postoperative complication follow-up data and relevant clinical data were compared between the two groups.

RESULTS

There were no significant differences between Group 1 and Group 2 in postoperative complications (6.1% vs 6.7%, P = 0.679), anal exhaust time or blood loss. The follow-up prevalence of reflux gastritis indicated no significant difference between Group 1 and Group 2 (68.2% vs 51.7%, P = 0.109). The follow-up European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 scores revealed no evident difference between Group 1 and Group 2 as well. Group 1 had a shorter operating time than Group 2 on average (234.6 min vs 262.0 min, P = 0.017).

CONCLUSION

Combined with Billroth II reconstruction, Braun anastomosis has been applied due to its ability to reduce the prevalence of reflux gastritis. Whereas in this study, the prevalence of reflux gastritis showed no significant difference, leading to a conclusion that under the circumstance of Braun anastomosis costing more time and more money, simple Billroth II reconstruction should be widely applied.

Laparoscopic treatment of a recurrent biliary stone forming around a Hem-o-lok clip in a patient with previous gastrectomies: Case report

RATIONALE

A history of gastrectomy is associated with an increased incidence of gallstones requiring surgery. Endoscopic retrograde cholangiopancreatography is challenging for patients who undergo total or Billroth II gastrectomy. Laparoscopic common bile duct exploration (LCBDE) has been attempted in such cases. Herein, we report a case of choledocholithiasis in which a stone formed around a migrated Hem-o-lok clip.

PATIENT CONCERNS

A 67-year-old man was admitted to the hospital for acute right upper abdominal pain. He had a history of 2 open gastric cancer surgeries in the previous seven years and had undergone LCBDE 12 months prior to this admission. Postoperative examination revealed recurrence of bile duct stones.

INTERVENTIONS

The patient underwent repeat LCBDE plus primary closure with an evaluation of abdominal adhesion. A stone had formed around a Hem-o-lok clip in the common bile duct was removed.

OUTCOMES

The patient had an uneventful recovery with no stone recurrence or movement of the remaining Hem-o-lok clips after a 1-year follow-up.

LESSONS

LCBDE with primary closure should be carefully considered in patients with certain gallstone diseases after complicated upper abdominal surgery.Postoperative clip migration is a rare complication; hence care must be taken in placing the clip appropriately to ensure that it is not too close to the common bile duct.

Efficacy and safety of the rotatable sphincterotome during ERCP in patients with prior Billroth II gastrectomy (with videos)

BACKGROUND

Selective biliary cannulation (SBC) is currently accepted as the first challenge of endoscopic retrograde cholangiopancreatography (ERCP), especially in patients with altered anatomy such as Billroth II gastrectomy. A rotatable sphincterotome (RS) might be considered useful for guiding the directional axis of SBC. This study aimed to evaluate the efficacy and safety of RS for biliary cannulation in patients with prior Billroth II gastrectomy.

METHODS

This is a retrospective cohort study conducted to compare the efficacy and safety between RS (RS group) and conventional sphincterotome of pulling arciform knife (PAF, PAF group). The success rate of SBC and endoscopic sphincterotomy (EST) were evaluated in both the groups. Moreover, the outcomes of the procedure and adverse events were also compared between the two groups.

RESULTS

Eighty-six consecutive prior Billroth II gastrectomy patients who underwent ERCP with RS or PAF during the study period were enrolled. After excluding 7 patients, there were 41 patients in the RS group and 38 in the PAF group. The baseline characteristics were similar in both the groups. There was no significant difference in the clinical success rates of SBC in RS group (95.12%) versus PAF group (84.21%), (P = 0.1082). Successful SBC within 5 min was 87.80% in RS group and 23.68% in PAF group (P < 0.0001). The success rate of EST was 89.74% in RS group and 28.13% in PAF group (P < 0.0001). The incidence of post-ERCP pancreatitis (PEP) showed significant differences between RS (2.44%) and PAF groups (21.05%; P = 0.0061).

CONCLUSIONS

Although RS has comparable success rates of SBC over PAF in patients with prior Billroth II gastrectomy, RS has facilitated the procedure by increasing the success rate of EST and SBC within 5 min, and the incidence of PEP was lowered as well.

Mirizzi syndrome in a patient with partial gastrectomy with Billroth II anastomosis: A case report

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Obstructive jaundice may be a challenge for differential diagnosis.

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Mirizzi Syndrome may simulate clinical and radiological presentation of common bile duct stones.

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ERCP hardly achieves cannulation of biliary duct in altered anatomy, so gastroscope may be a correct choice in these cases.

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Surgical treatment is essential in Mirizzi Syndrome.

Introduction

Mirizzi Syndrome (MS) is a common bile duct (CBD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Radiological evaluation may mistake it for CBD stones in jaundiced patient, especially in those who have altered anatomy of upper gastrointestinal (e.g. sub-total gastrectomy – STG – with Billroth I or II anastomosis).

Presentation of case

A 69-year-old male with a history of STG Billroth-II 25 years prior, accessed hospital for abdominal pain and jaundice with increasing in hepatic laboratory tests. Ultrasound of abdomen, CT scan and MRCP diagnosed CBD stones, so endoscopic retrograde cholangiopancreatography (ERCP) was performed, using a gastroscope to reach papillary region and to achieve cannulation of biliary duct. During cholangiography patient resulted affected by Mirizzi syndrome type I, so laparoscopic cholecystectomy was performed and cystic duct was moved away.

Discussion

This rare case shows how it’s easy to delay the correct treatment when a wrong radiological diagnosis is made. Moreover, ERCP remains a challenging procedure in patients with altered anatomy, such as STG B–II, and in this case gastroscope was needed for cannulation, due to the need of frontal view.

Conclusion

This rare case report highlights the importance of not forgetting MS in the differential diagnosis of biliary obstruction, especially in those patients with upper GI altered anatomy. Physicians with expertise in ERCP should always consider altered anatomy as a factor which may confuse radiologist in diagnosis, so in this case MS may be discovered or confirmed at ERCP.