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Cap-assisted ERCP in patients with a Billroth II gastrectomy
Cap-assisted ERCP in patients with a Billroth II gastrectomy Chang-Hwan Park, MD, Wan-Sik Lee, MD, Young-Eun Joo, MD, Hyun-Soo Kim, MD, Sung-Kyu Choi, MD, Jong-Sun Rew, MD Gwangju, Republic of Korea
Background: ERCP is difficult in patients with a Billroth II gastrectomy because of anatomical changes. Objective: Cap-assisted ERCP can improve the cannulation rate and the success rate of stone removal. Design: Case series. Setting: A tertiary referral center. Patients and Interventions: Ten consecutive patients with bile-duct stones (9) or a distal common bile duct stricture (1), who had previously undergone Billroth II gastrectomy and were referred for ERCP, were analyzed for the outcome of their ERCP. All procedures were carried out with a cap-fitted regular forward-viewing endoscope. Main Outcome Measurements: Ability to perform afferent loop intubation and bile-duct cannulation. Results: Of 10 patients in whom ERCP was attempted, afferent loop intubation and selective bile-duct cannulation were achieved in all patients (100%). Endoscopic sphincterotomy (EST) was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and endoscopic papillary balloon dilation in 2 patients. There were no serious complications in the patients. Limitations: Small sample size, single-center experience. Conclusions: Diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted endoscope.
ERCP is widely used for the diagnosis and treatment of pancreatobiliary disease.1 Reports from the 1990s indicate that successful cannulation rates in an intact stomach at or above 95% are consistently achieved by experienced endoscopists, and rates above 80% are a goal of training programs in ERCP.2 However, patients with surgically altered GI anatomy present a challenge to the therapeutic endoscopist.3 In the literature, the success rate of ERCP in patients with a prior Billroth II gastrectomy varied from 52% to 92%.4-8 There are several obstacles to successful stone removal in these patients. First, it may be difficult to identify the afferent loop and to advance the tip of the endoscope to the papilla. Second, if and when the papilla is reached, the inverted anatomy of the Billroth II state makes selective cannulation of the bile duct more difficult. Third, performing a sphincterotomy in a patient who had a Billroth II is more difficult than in the normal anatomic situation.9
Cap-assisted endoscopy has been widely used in EMR procedures for the treatment of early gastric cancer10 and can also facilitate the detection and visualization of lesions that are situated in ‘‘blind areas’’ of the GI tract.11,12 The technique can also be used to help afferent loop intubation and ampulla cannulation in patients with a prior Billroth II gastrectomy.13 Therefore, we report the use of cap to perform ERCP in patients with a prior Billroth II gastrectomy.
PATIENTS AND METHODS
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.04.024
From March 2006 to October 2006, 10 consecutive patients with bile-duct stones (9) or a common bile duct (CBD) stricture (1), who had previously undergone Billroth II gastrectomy and referred for ERCP, were analyzed for outcome of their ERCP. Only patients with an intact papilla were included. Patients were excluded from the analysis if there were a history of a previous endoscopic sphincterotomy (EST), endoscopic papillary balloon dilation (EPBD), and biliary or pancreatic stent, and with known gastric or afferent loop obstruction. One endoscopist performed all procedures. All patients gave written informed consent to undergo the procedure.
612 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
www.giejournal.org
Abbreviations: CBD, common bile duct; EPBD, endoscopic papillary balloon dilation; EST, endoscopic sphincterotomy.
Park et al
Figure 1. Endoscopic view of the papilla. The duodenal base of the papilla was pushed with the 11-o’clock margin of the cap, the papilla was turned to face the endoscope. The cap kept a regular distance and visual field between the papilla and the tip of the endoscope.
Cap-assisted ERCP in patients with a Billroth II gastrectomy
Figure 2. Endoscopic sphincterotomy by using a Soehendra Billroth II sphincterotome. Endoscopic sphincterotomy is performed along the guidewire directed at 5 o’clock.
OBSERVATIONS Endoscopic procedures All ERCP procedures were carried out with a cap-fitted regular forward-viewing endoscope (Olympus GIF 230; Olympus Optical Co, Ltd, Tokyo, Japan). A transparent cap (Distal Attachments MH-593; Olympus) was attached to the tip of the endoscope. Patients were sedated with midazolam (2.5-10 mg) or diazepam (5-10 mg) supplemented if necessary with fentanyl (0.05-0.1 mg). All patients received oxygen administered by nasal prong and were monitored by pulse oximetry and electrocardiography. Antibiotics were not routinely given as a prophylaxis. The afferent loop was intubated with minimal air insufflation. The entrance to the afferent loop was achieved by inserting the distal end of the transparent cap into the afferent stoma. The proper direction in acute angulations was determined by looking through the transparent cap that kept a certain distance and visual field from the any mucosal folds that obscured the lumen. Reduction of any loops created during the procedure was facilitated by ‘‘hooking’’ of the longer tip of the cap-fitted endoscope against a mucosal fold. The selective CBD cannulation was achieved by using a straight catheter. The duodenal base of the papilla was pushed with the 11-o’clock margin of the cap, the papilla was turned to face the endoscope (Fig. 1) and then the tip of the catheter was properly located to the correct access to the CBD at the 5-o’clock position. EST was performed by using a Soehendra Billroth II sphincterotome (Fig. 2). The proper direction of EST was achieved by pushing the duodenal wall at 11 o’clock with the cap. An EPBD was performed in cases of larger stones and inadequate EST (Fig. 3). The papilla was dilated up to 15 mm. After ESTand EPBD, stones were extracted by using Dormia baskets and/or balloon tipped catheters (Fig. 4). Mechanical lithotripsy was used when necessary and a biliary endoprosthesis was inserted in case of incomplete stone removal. www.giejournal.org
Ten patients underwent a total of 22 ERCP examinations. There were 9 men and 1 woman, with a median age of 67 years (range 52-80 years). The indications for ERCP were obstructive jaundice because of stones (9) and CBD dilatation from a stricture (1). Afferent loop intubation and cannulation of the ampulla was successful in 22 of 22 (100%) and 22 of 22 (100%) examinations, respectively. EST was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and EPBD in 2 patients. Complete stone removal in 1 endoscopic session was achieved in 3 patients. In the other 6 patients, complete stone removal was achieved by multiple endoscopic sessions (range 2-6). Mechanical lithotripsy was used in 2 patients with larger stones (1.5 cm and 2.5 cm). There were no serious complications in the patients. Only 1 patient with distal CBD stricture showed mild pancreatitis after EPBD. He recovered uneventfully in a few days. There were no deaths related to the procedure in the patients. The results are summarized in Table 1.
DISCUSSION Diagnostic and therapeutic ERCP in patients with a prior Billroth II gastrectomy poses one of the great challenges to the biliary endoscopists. Recently, the degree of difficulty of ERCP has been suggested as way of assessing outcomes on the basis of procedural difficulty.14 Billroth II diagnostic ERCP has been suggested as difficulty grade 2, and Billroth II therapeutic as difficulty grade 3.2 Two problems are inherent in Billroth II ERCP. First, the afferent loop intubation can be difficult because of the sharp angulation of the anastomosis or a long afferent loop, especially in a Braun anastomosis, or sometimes because of loop Volume 66, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 613
Cap-assisted ERCP in patients with a Billroth II gastrectomy
Park et al
Figure 4. A biliary stone extracted by using a Dormia basket.
Figure 3. Endoscopic view of papillary balloon dilation through the transparent cap.
TABLE 1. Results of cap-assisted ERCP in 10 patients with a Billroth II gastrectomy Patient no.
Age (y)
Sex
Indication
Sessions
Procedure time (min)
Results
68
Success
362
Success
1
62
M
CBD stone (1 cm)
2 (EST, EPBD)
2
52
M
CBD stones (5-6 mm)
6 (EST)
3
71
F
CBD stone (1 cm)
3 (EST, EPBD)
92
Success
4
79
M
CBD stricture
2 (EST, EPBD)
74
Success
5
67
M
CBD stone (2.5 cm)
2 (EST)
73
Success
6
57
M
CBD stone (5-6 mm)
2 (EST)
42
Success
7
53
M
CBD stone (1 cm)
1 (EST)
16
Success
8
64
M
CBD stone (1.5 cm)
2 (EST)
54
Success
9
80
M
CBD stone (1 cm)
1 (EST)
37
Success
10
78
M
CBD stone (5-6 mm)
1 (EST)
18
Success
formation at the Treiz ligament. The second problem is that the cannulation has to be done in an opposite direction.15 In the present case series, afferent loop intubation was successful in all examinations. The high rate of success was achieved by using the cap-fitted technique. Therefore, the present case series suggests that the cap-fitted technique could improve the success rate of the afferent loop intubation, and that the cap can be very useful in patients with a long afferent loop, such as a Braun anastomosis. The cap-fitted technique has certain benefits for afferent loop intubation. First, the cap can provide a regular distance between the mucosal folds and the tip of the endoscope, which is essential for the adequate visual field to show the nature of any acute angulations encountered. Also, the cap can facilitate the displacement of any mucosal folds that obscure the lumen.16 Therefore, the cap is very useful for overcoming the sharp angulations. Second, because of cap attachment, the longer bending section can be useful for reducing loop formation. In the shorter
bending section, the vector of force is more directed along the shaft of the endoscope, increasing loop formation, but in the longer bending section, the vector of force is more directed along the tip of the endoscope, reducing loop formation. Third, the cap can also facilitate ‘‘hooking’’ of the tip of the endoscope against a mucosal fold when the endoscopist is attempting to reduce any loops created during the procedure. The risk of perforation can be reduced by avoiding excessive looping and not attempting blind rotational maneuvers. Cap-assisted ERCP can also improve the success rate of CBD cannulation. In the present case series, selective CBD cannulation was achieved in all examinations. For the selective CBD cannulation, it is very important to keep a regular distance and visual field between the tip of the scope and the papilla. A short distance limits the visual field, and a long distance limits fine control of the catheter movement. With a cap, the regular distance and visual field between the tip of the scope and the papilla can be achieved
614 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
www.giejournal.org
Park et al
easily, which is helpful for the fine control of the catheter. Compared with the papilla in an intact stomach, the papilla in Billroth II gastrectomy is in a reversed direction. For successful CBD cannulation in patients with Billroth II, the most important step is keeping the tip of the straight catheter in a position that will allow it to access the CBD at the 5-o’clock position. In our experience, pushing the cap against the duodenal wall at an 11-o’clock position leads the tip of the catheter to the proper position. In the same method, the cap is also very useful for keeping the Soehendra Billroth II sphincterotome in a proper position. After deep CBD cannulation and EST, further therapeutic procedures, including EPBD, stone removal with Dormia baskets and/or balloon tipped catheters, and mechanical lithotripsy, can be performed without difficulty. Variable techniques, such as the stiffer scope with a stiffened tube, the pediatric scope for long afferent loop, placement of a guidewire, have been used for the successful ERCP in patients with a prior Billroth II gastrectomy.15 Recently, 1 study addressed the usefulness of doubleballoon endoscopy for the diagnosis and treatment in patients with surgically reconstructed GI tracts, including 5 patients with Billroth II gastrojejunostomy. They performed 4 ERCP examinations.17 No complications were encountered during and after the procedures. Although double-balloon endoscopy can be very useful for the successful afferent loop intubation and diagnostic ERCP, availability in therapeutic ERCP has not been determined. In conclusion, diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted technique.
Cap-assisted ERCP in patients with a Billroth II gastrectomy 3. Cheon YK, Fogel EL. ERCP topics. Endoscopy 2006;38:1092-7. 4. Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut 1984;25:971-4. 5. Osnes M, Rosseland AR, Aabaken L. Endoscopic retrograde cholangiography and endoscopic papillotomy in patients with previous Billroth-II resection. Gut 1986;27:1193-8. 6. Faylona JM, Qadir A, Chung SC, et al. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Endoscopy 2000;32:589-90. 7. Swarnakar K, Stamatakis JD, Young WT. Diagnostic and therapeutic endoscopic retrograde cholangiopancreaticography after Billroth II gastrectomy: safe provision in a district general hospital. Ann R Coll Surg Engl 2005;87:274-6. 8. Bagci S, Tuzen A, Ates Y, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography in patients with Billroth II anastomosis. Hepatogastroenterology 2005;52:356-9. 9. Berman JJ, van Berkel AM, Bruno MJ, et al. A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy. Gastrointest Endosc 2001;53:19-26. 10. Matsuzaki K, Nagao S, Kawaguchi A, et al. Newly designed soft prelooped cap for endoscopic mucosal resection of gastric lesions. Gastrointest Endosc 2003;57:242-6. 11. Yap CK, Ng HS. Cap-fitted gastroscopy improves visualization and targeting of lesions. Gastrointest Endosc 2001;53:93-5. 12. Matsushita M, Hajiro K, Okazaki K, et al. Efficacy of total colonoscopy with a transparent cap in comparison with colonoscopy without a cap. Endoscopy 1998;30:444-7. 13. Lee YT. Cap-assisted endoscopic retrograde cholangiography in a patient with a Billroth II gastrectomy. Endoscopy 2004;36:666. 14. Cotton PB. Income and outcome metrics for the objective evaluation of ERCP and alternative methods. Gastrointest Endosc 2002;56: S283-90. 15. Lin LF, Siauw CP, Ho KS, et al. ERCP in post-Billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol 1999;94: 144-8. 16. Lee YT, Hui AJ, Wong VWS, et al. Improved colonoscopy success rate with a distally attached mucosectomy cap. Endoscopy 2006;38: 739-42. 17. Tanaka S, Mitsui K, Tatsuguchi A, et al. Usefulness of double-balloon endoscopy for diagnosis and treatment of the post-operative gastrointestinal tract [abstract]. Gastrointest Endosc 2006;63:AB291.
DISCLOSURE The authors have no disclosures to make. Received December 1, 2006. Accepted April 30, 2007.
REFERENCES 1. Cotton PB. Progress report: ERCP. GUT 1977;18:316-41. 2. Baron TH, Petersen BT, Mergener K, et al. Quality indicators for endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 2006;63:S29-34.
www.giejournal.org
Current affiliations: Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, South Korea. Reprints requests: Chang-Hwan Park, MD, Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, 8 Hak-dong, Dong-ku, Gwangju, 501-757, Korea.
Volume 66, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 615
Background: ERCP is difficult in patients with a Billroth II gastrectomy because of anatomical changes. Objective: Cap-assisted ERCP can improve the cannulation rate and the success rate of stone removal. Design: Case series. Setting: A tertiary referral center. Patients and Interventions: Ten consecutive patients with bile-duct stones (9) or a distal common bile duct stricture (1), who had previously undergone Billroth II gastrectomy and were referred for ERCP, were analyzed for the outcome of their ERCP. All procedures were carried out with a cap-fitted regular forward-viewing endoscope. Main Outcome Measurements: Ability to perform afferent loop intubation and bile-duct cannulation. Results: Of 10 patients in whom ERCP was attempted, afferent loop intubation and selective bile-duct cannulation were achieved in all patients (100%). Endoscopic sphincterotomy (EST) was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and endoscopic papillary balloon dilation in 2 patients. There were no serious complications in the patients. Limitations: Small sample size, single-center experience. Conclusions: Diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted endoscope.
ERCP is widely used for the diagnosis and treatment of pancreatobiliary disease.1 Reports from the 1990s indicate that successful cannulation rates in an intact stomach at or above 95% are consistently achieved by experienced endoscopists, and rates above 80% are a goal of training programs in ERCP.2 However, patients with surgically altered GI anatomy present a challenge to the therapeutic endoscopist.3 In the literature, the success rate of ERCP in patients with a prior Billroth II gastrectomy varied from 52% to 92%.4-8 There are several obstacles to successful stone removal in these patients. First, it may be difficult to identify the afferent loop and to advance the tip of the endoscope to the papilla. Second, if and when the papilla is reached, the inverted anatomy of the Billroth II state makes selective cannulation of the bile duct more difficult. Third, performing a sphincterotomy in a patient who had a Billroth II is more difficult than in the normal anatomic situation.9
Cap-assisted endoscopy has been widely used in EMR procedures for the treatment of early gastric cancer10 and can also facilitate the detection and visualization of lesions that are situated in ‘‘blind areas’’ of the GI tract.11,12 The technique can also be used to help afferent loop intubation and ampulla cannulation in patients with a prior Billroth II gastrectomy.13 Therefore, we report the use of cap to perform ERCP in patients with a prior Billroth II gastrectomy.
PATIENTS AND METHODS
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.04.024
From March 2006 to October 2006, 10 consecutive patients with bile-duct stones (9) or a common bile duct (CBD) stricture (1), who had previously undergone Billroth II gastrectomy and referred for ERCP, were analyzed for outcome of their ERCP. Only patients with an intact papilla were included. Patients were excluded from the analysis if there were a history of a previous endoscopic sphincterotomy (EST), endoscopic papillary balloon dilation (EPBD), and biliary or pancreatic stent, and with known gastric or afferent loop obstruction. One endoscopist performed all procedures. All patients gave written informed consent to undergo the procedure.
612 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
www.giejournal.org
Abbreviations: CBD, common bile duct; EPBD, endoscopic papillary balloon dilation; EST, endoscopic sphincterotomy.
Park et al
Figure 1. Endoscopic view of the papilla. The duodenal base of the papilla was pushed with the 11-o’clock margin of the cap, the papilla was turned to face the endoscope. The cap kept a regular distance and visual field between the papilla and the tip of the endoscope.
Cap-assisted ERCP in patients with a Billroth II gastrectomy
Figure 2. Endoscopic sphincterotomy by using a Soehendra Billroth II sphincterotome. Endoscopic sphincterotomy is performed along the guidewire directed at 5 o’clock.
OBSERVATIONS Endoscopic procedures All ERCP procedures were carried out with a cap-fitted regular forward-viewing endoscope (Olympus GIF 230; Olympus Optical Co, Ltd, Tokyo, Japan). A transparent cap (Distal Attachments MH-593; Olympus) was attached to the tip of the endoscope. Patients were sedated with midazolam (2.5-10 mg) or diazepam (5-10 mg) supplemented if necessary with fentanyl (0.05-0.1 mg). All patients received oxygen administered by nasal prong and were monitored by pulse oximetry and electrocardiography. Antibiotics were not routinely given as a prophylaxis. The afferent loop was intubated with minimal air insufflation. The entrance to the afferent loop was achieved by inserting the distal end of the transparent cap into the afferent stoma. The proper direction in acute angulations was determined by looking through the transparent cap that kept a certain distance and visual field from the any mucosal folds that obscured the lumen. Reduction of any loops created during the procedure was facilitated by ‘‘hooking’’ of the longer tip of the cap-fitted endoscope against a mucosal fold. The selective CBD cannulation was achieved by using a straight catheter. The duodenal base of the papilla was pushed with the 11-o’clock margin of the cap, the papilla was turned to face the endoscope (Fig. 1) and then the tip of the catheter was properly located to the correct access to the CBD at the 5-o’clock position. EST was performed by using a Soehendra Billroth II sphincterotome (Fig. 2). The proper direction of EST was achieved by pushing the duodenal wall at 11 o’clock with the cap. An EPBD was performed in cases of larger stones and inadequate EST (Fig. 3). The papilla was dilated up to 15 mm. After ESTand EPBD, stones were extracted by using Dormia baskets and/or balloon tipped catheters (Fig. 4). Mechanical lithotripsy was used when necessary and a biliary endoprosthesis was inserted in case of incomplete stone removal. www.giejournal.org
Ten patients underwent a total of 22 ERCP examinations. There were 9 men and 1 woman, with a median age of 67 years (range 52-80 years). The indications for ERCP were obstructive jaundice because of stones (9) and CBD dilatation from a stricture (1). Afferent loop intubation and cannulation of the ampulla was successful in 22 of 22 (100%) and 22 of 22 (100%) examinations, respectively. EST was successful in all 10 patients (100%). All stones were removed by EST alone in 7 patients and by both EST and EPBD in 2 patients. Complete stone removal in 1 endoscopic session was achieved in 3 patients. In the other 6 patients, complete stone removal was achieved by multiple endoscopic sessions (range 2-6). Mechanical lithotripsy was used in 2 patients with larger stones (1.5 cm and 2.5 cm). There were no serious complications in the patients. Only 1 patient with distal CBD stricture showed mild pancreatitis after EPBD. He recovered uneventfully in a few days. There were no deaths related to the procedure in the patients. The results are summarized in Table 1.
DISCUSSION Diagnostic and therapeutic ERCP in patients with a prior Billroth II gastrectomy poses one of the great challenges to the biliary endoscopists. Recently, the degree of difficulty of ERCP has been suggested as way of assessing outcomes on the basis of procedural difficulty.14 Billroth II diagnostic ERCP has been suggested as difficulty grade 2, and Billroth II therapeutic as difficulty grade 3.2 Two problems are inherent in Billroth II ERCP. First, the afferent loop intubation can be difficult because of the sharp angulation of the anastomosis or a long afferent loop, especially in a Braun anastomosis, or sometimes because of loop Volume 66, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 613
Cap-assisted ERCP in patients with a Billroth II gastrectomy
Park et al
Figure 4. A biliary stone extracted by using a Dormia basket.
Figure 3. Endoscopic view of papillary balloon dilation through the transparent cap.
TABLE 1. Results of cap-assisted ERCP in 10 patients with a Billroth II gastrectomy Patient no.
Age (y)
Sex
Indication
Sessions
Procedure time (min)
Results
68
Success
362
Success
1
62
M
CBD stone (1 cm)
2 (EST, EPBD)
2
52
M
CBD stones (5-6 mm)
6 (EST)
3
71
F
CBD stone (1 cm)
3 (EST, EPBD)
92
Success
4
79
M
CBD stricture
2 (EST, EPBD)
74
Success
5
67
M
CBD stone (2.5 cm)
2 (EST)
73
Success
6
57
M
CBD stone (5-6 mm)
2 (EST)
42
Success
7
53
M
CBD stone (1 cm)
1 (EST)
16
Success
8
64
M
CBD stone (1.5 cm)
2 (EST)
54
Success
9
80
M
CBD stone (1 cm)
1 (EST)
37
Success
10
78
M
CBD stone (5-6 mm)
1 (EST)
18
Success
formation at the Treiz ligament. The second problem is that the cannulation has to be done in an opposite direction.15 In the present case series, afferent loop intubation was successful in all examinations. The high rate of success was achieved by using the cap-fitted technique. Therefore, the present case series suggests that the cap-fitted technique could improve the success rate of the afferent loop intubation, and that the cap can be very useful in patients with a long afferent loop, such as a Braun anastomosis. The cap-fitted technique has certain benefits for afferent loop intubation. First, the cap can provide a regular distance between the mucosal folds and the tip of the endoscope, which is essential for the adequate visual field to show the nature of any acute angulations encountered. Also, the cap can facilitate the displacement of any mucosal folds that obscure the lumen.16 Therefore, the cap is very useful for overcoming the sharp angulations. Second, because of cap attachment, the longer bending section can be useful for reducing loop formation. In the shorter
bending section, the vector of force is more directed along the shaft of the endoscope, increasing loop formation, but in the longer bending section, the vector of force is more directed along the tip of the endoscope, reducing loop formation. Third, the cap can also facilitate ‘‘hooking’’ of the tip of the endoscope against a mucosal fold when the endoscopist is attempting to reduce any loops created during the procedure. The risk of perforation can be reduced by avoiding excessive looping and not attempting blind rotational maneuvers. Cap-assisted ERCP can also improve the success rate of CBD cannulation. In the present case series, selective CBD cannulation was achieved in all examinations. For the selective CBD cannulation, it is very important to keep a regular distance and visual field between the tip of the scope and the papilla. A short distance limits the visual field, and a long distance limits fine control of the catheter movement. With a cap, the regular distance and visual field between the tip of the scope and the papilla can be achieved
614 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 3 : 2007
www.giejournal.org
Park et al
easily, which is helpful for the fine control of the catheter. Compared with the papilla in an intact stomach, the papilla in Billroth II gastrectomy is in a reversed direction. For successful CBD cannulation in patients with Billroth II, the most important step is keeping the tip of the straight catheter in a position that will allow it to access the CBD at the 5-o’clock position. In our experience, pushing the cap against the duodenal wall at an 11-o’clock position leads the tip of the catheter to the proper position. In the same method, the cap is also very useful for keeping the Soehendra Billroth II sphincterotome in a proper position. After deep CBD cannulation and EST, further therapeutic procedures, including EPBD, stone removal with Dormia baskets and/or balloon tipped catheters, and mechanical lithotripsy, can be performed without difficulty. Variable techniques, such as the stiffer scope with a stiffened tube, the pediatric scope for long afferent loop, placement of a guidewire, have been used for the successful ERCP in patients with a prior Billroth II gastrectomy.15 Recently, 1 study addressed the usefulness of doubleballoon endoscopy for the diagnosis and treatment in patients with surgically reconstructed GI tracts, including 5 patients with Billroth II gastrojejunostomy. They performed 4 ERCP examinations.17 No complications were encountered during and after the procedures. Although double-balloon endoscopy can be very useful for the successful afferent loop intubation and diagnostic ERCP, availability in therapeutic ERCP has not been determined. In conclusion, diagnostic and therapeutic ERCP with a cap-fitted regular forward-viewing endoscope was successful in all patients with a prior Billroth II gastrectomy. The high rate of successful ERCP was achieved by improving afferent loop intubation and bile-duct cannulation with a cap-fitted technique.
Cap-assisted ERCP in patients with a Billroth II gastrectomy 3. Cheon YK, Fogel EL. ERCP topics. Endoscopy 2006;38:1092-7. 4. Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut 1984;25:971-4. 5. Osnes M, Rosseland AR, Aabaken L. Endoscopic retrograde cholangiography and endoscopic papillotomy in patients with previous Billroth-II resection. Gut 1986;27:1193-8. 6. Faylona JM, Qadir A, Chung SC, et al. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Endoscopy 2000;32:589-90. 7. Swarnakar K, Stamatakis JD, Young WT. Diagnostic and therapeutic endoscopic retrograde cholangiopancreaticography after Billroth II gastrectomy: safe provision in a district general hospital. Ann R Coll Surg Engl 2005;87:274-6. 8. Bagci S, Tuzen A, Ates Y, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography in patients with Billroth II anastomosis. Hepatogastroenterology 2005;52:356-9. 9. Berman JJ, van Berkel AM, Bruno MJ, et al. A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy. Gastrointest Endosc 2001;53:19-26. 10. Matsuzaki K, Nagao S, Kawaguchi A, et al. Newly designed soft prelooped cap for endoscopic mucosal resection of gastric lesions. Gastrointest Endosc 2003;57:242-6. 11. Yap CK, Ng HS. Cap-fitted gastroscopy improves visualization and targeting of lesions. Gastrointest Endosc 2001;53:93-5. 12. Matsushita M, Hajiro K, Okazaki K, et al. Efficacy of total colonoscopy with a transparent cap in comparison with colonoscopy without a cap. Endoscopy 1998;30:444-7. 13. Lee YT. Cap-assisted endoscopic retrograde cholangiography in a patient with a Billroth II gastrectomy. Endoscopy 2004;36:666. 14. Cotton PB. Income and outcome metrics for the objective evaluation of ERCP and alternative methods. Gastrointest Endosc 2002;56: S283-90. 15. Lin LF, Siauw CP, Ho KS, et al. ERCP in post-Billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol 1999;94: 144-8. 16. Lee YT, Hui AJ, Wong VWS, et al. Improved colonoscopy success rate with a distally attached mucosectomy cap. Endoscopy 2006;38: 739-42. 17. Tanaka S, Mitsui K, Tatsuguchi A, et al. Usefulness of double-balloon endoscopy for diagnosis and treatment of the post-operative gastrointestinal tract [abstract]. Gastrointest Endosc 2006;63:AB291.
DISCLOSURE The authors have no disclosures to make. Received December 1, 2006. Accepted April 30, 2007.
REFERENCES 1. Cotton PB. Progress report: ERCP. GUT 1977;18:316-41. 2. Baron TH, Petersen BT, Mergener K, et al. Quality indicators for endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 2006;63:S29-34.
www.giejournal.org
Current affiliations: Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, South Korea. Reprints requests: Chang-Hwan Park, MD, Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, 8 Hak-dong, Dong-ku, Gwangju, 501-757, Korea.
Volume 66, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 615