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Endoscopic retrograde cholangiopancreatography in patients with gastrectomy and gastrojejunostomy (Billroth II)
164
Endoscopic retrograde cholangiopancreatography in patients with gastrectomy and gastrojejunostomy (Billroth II) A case for the forward look
Ronald M. Katon, Marcia K. Bilbao, Joseph A. Parent, Frederic W. Smith,
Endoscopic cannulation of the duodenal papilla in patients with gastrojejunostomy presents special problems that have been solved by these authors who recommend use of the forward viewing instrument. Particular caution is urged in endoscopy of the afferent limb.
There is presently a large body of experience with cannulation of the papilla of Vater for retrograde cholangiopancreatography (ERCP).'-6 Although most studies have been done on patients with intact gastrointestinal tracts, Oi 7 and Safrany· have successfully used a side-viewing fiberscope to cannulate patients with gastrojejunostomy after a Billroth II gastric resection. Our own experience with such patients suggests thatcannulation through the afferent loop of a Billroth II anastomosis may be facilitated by the use of a fiberscopic endoscope with a forward-viewing optical system. METHODS Twelve procedures were performed on 10 patients with a distal gastrectomy and Billroth II gastrojejunostomy. The indications, contrindications, and specific aspects of technique employed are published elsewhere and are similar to those of other workers. ' - 6 The Olympus fiberduodenscope (jFB), a side-viewing endoscope with a cannula deflector, was used with the first 4 patients and the Olympus GIF-D forward-viewing fiberscope which lacks a cannula control lever with the last 6. The fifth patient was studied on 2 separate occasions with the GIF-D to resolve a radiologic uncertainty; the tenth was studied with both instruments at the same session.
MD MD MD MD
Portland, Oregon
case 6 (see below). The papilla was visualized en face in all, and despite the lack of a cannula deflector, was successfully cannulated in 3 patients (Figures 2, 3). One of these patients was re-endoscoped with the GIF-D and succcessfully cannulated a second time to resolve a question of interpretation of x-rays. One of the 3 failures (case 10) was re-endoscoped with the JFB at the same session and successfully cannulated. Case 6, a patient with decompensated Laennec's cirrhosis and liver tests suggesting obstruction, developed signs of perforation following a prolonged effort to negotiate a tortu-
Table I
Comparison of side-viewing and forward-viewing instruments Afferent loop No. pts. Attempts entered 4 5 4
]FB (lateral) 6 7 7 GIF-D (forward) 'Presumed retroperitoneal duodenal perforation
Papilla seen 3
7
Cannu- Complilated cations 2 0
4
l'
RESULTS Our experience is summarized in Table I. 1. Side-viewing Fiberduodenscope (JFB). In 5 procedures the afferent loop was entered in 4, the endoscope advanced to the papilla in 3 and was cannulated successfully in 2. Fluoroscopy during the procedure was not helpful in identifying the loop being entered. Previous hypotonic duodenography was used in 2 cases and was useful in predicting difficulties with a redundant afferent loop but did not otherwise facilitate the procedure. Delays and difficulties in identifying and entering the afferent loop and in introducing the instrument through the loop to the papilla of Vater were encountered with all patients. Figure 1 shows a pancreatogram made with this instrument. 2. Forward-viewing Fiberscope (GIF-D). In all 6 patients the afferent loop was easily identified, entered, ancj followed to its blind termination. There were no problems except in
Figure 1. Using the side-viewing duodenoscope, the pancreatic duct has been cannulated and visualized (lateral view), showing slight enlargement and irregularity of the ducts consistent with the patient's advanced age.
ous, fixed, afferent loop and several unsuccessful attempts to introduce a catheter into the papilla. She was explored after x-rays showed contrast agent intramurally in the duodenum, as well as retroperitoneal and free peritoneal gas. She died 24 days later in liver failure. Neither at surgery nor at postmortem examination could the site of perforation be identified. DISCUSSION When patients with gastrojejunostomy after Billroth II partial gastrectomy develop indications for ERCP, thepailla of Vater must be approached in a retrograde fashion through the afferent loop. This maneuver has been difficult in our experience with the side-viewing fiberscope routinely used for cannulation in the intact upper gastrointestinal tract. This difficulty is due in part to an optical system which
From the Departments of Medicine and Diagnostic Radiology, University of Oregon Medical School, and the Department of Medicine, Veterans Administration Hospital, Portland, Oregon. Reprint requests: Dr. Ronald M. Katon, Department of Medicine, University of Oregon Medical School, Portland, Oregon 97201. GASTROINTESTINAL ENDOSCOPY
165
peritoneal adhesions, may make the procedure more difficult and increase the risk of complications. Addendum: Since this paper was written, cannulation was successful in 2 patients with a Billroth II gastric resection using the Olympus model GIF-K.
Figure 2. The front-viewing fiberscope is in place within the afferent loop; cannula is in the pancreatic duct, both ducts are visualized. The pancreatic duct shows minor irregularity consistent with the patient's advanced age. The filling defect in the duct is an air bubble. hampers the precise placementof the tip of the instrument into a selected opening. Using blind passage, moreover, we found, as did SMrany,8 that the efferent loop was preferentially entered. Difficulty encountered in passing the instrument retrogradely through the afferent loop related to its flexibility and to its tendency to move laterally rather than forward in the intestine. This was readily apparent at fluoroscopic observation. Use of the forward-viewi ng Olympus GIF- D fi berscope over the last 3 years in the evaluation of over 200 patients with Billroth II anastomoses has impresssed us with the ease of entering and examining both efferent and afferent loops. Furthermore, in the course of these studies we have frequently seen the papilla of Vater and have noted that the position of its orifice allows an excellent en face view when approached in this retrograde fashion. This experience, coupled with the above difficulties encountered with the side-viewing instrument, suggested the trial of the Olympus GIF-D for cannulation. As noted, the afferent loop was entered and the papilla identified in all 7 attempts, and cannulation was successful in 4. In the remaining 3 cases the addition of a deflecting lever to position the cannula more precisely may have allowed cannulation. The recently developed oblique (30°) viewing fiberscope (Olympus GIF-K) is equipped with such a lever and may prove useful in studying such patients. Regardless of which instrument is used, care must be taken in traversing the afferent loop. Theprocedure should not be attempted in the immediate postoperative period when distention mayproduce a leak at the suture lines. A long afferent loop, especially one associated with fixed flexures andVOLUME 21, NO.4, 1975
Figure 3. The front-viewing fiberscope is indenting the medial duodenal wall; cannula (arrow) is in the common bile duct.
REFERENCES 1. KASUGAI T, KUNO N, KOBAYASHI S, HATTORI K: Endoscopic pancreatocholangiography: I. The normal endoscopic pancreatocholangiogram. Gastroenterology 63:217, 1972 2. OGOSHI K, NIWA M, HARA Y, NEBEL aT: Endoscopic pancreatocholangiography in the evaluation of pancreatic and biliary disease. Gastroenterology 64:210, 1973 3. COTTON PB, SALMON PR, BLUMGART LH, BURWOOD Rj, DAVIES GT, LAWRIE BW, PIERCE jW, READ AE: Cannulation of papilla of Vater via fiberduodenoscope, assessment of retrograde cholangiography in sixty patients. Lancet 1:53, 1972 4. SAFRANY L, TARI j, BARNA L, TOROK I: Endoscopic retrograde cholangiography. Gastrointestinal Endoscopy 19:163, 1973 5. VENNES jA, SILVIS SE: Endoscopic visualization of bile and pancreatic ducts. Gastrointestinal Endoscopy 18: 149, 1972 6. KATON RM, LEE TG, PARENT jA, BILBAO MK, SMITH FW: Endoscopic retrograde cholangiopancreatography (ERCP): experience with 100 cases. Arner J Dig Dis 19:295,1974 7. all: Duodenoscopyduring pancreatic disease. Arch Fr Mal App Dig 61 :349, 1972 8. SAFRANY, L: Endoscopy and retrograde cholangiopancreatography after Billroth II operation. Endoscopy 4:198,1972
Endoscopic retrograde cholangiopancreatography in patients with gastrectomy and gastrojejunostomy (Billroth II) A case for the forward look
Ronald M. Katon, Marcia K. Bilbao, Joseph A. Parent, Frederic W. Smith,
Endoscopic cannulation of the duodenal papilla in patients with gastrojejunostomy presents special problems that have been solved by these authors who recommend use of the forward viewing instrument. Particular caution is urged in endoscopy of the afferent limb.
There is presently a large body of experience with cannulation of the papilla of Vater for retrograde cholangiopancreatography (ERCP).'-6 Although most studies have been done on patients with intact gastrointestinal tracts, Oi 7 and Safrany· have successfully used a side-viewing fiberscope to cannulate patients with gastrojejunostomy after a Billroth II gastric resection. Our own experience with such patients suggests thatcannulation through the afferent loop of a Billroth II anastomosis may be facilitated by the use of a fiberscopic endoscope with a forward-viewing optical system. METHODS Twelve procedures were performed on 10 patients with a distal gastrectomy and Billroth II gastrojejunostomy. The indications, contrindications, and specific aspects of technique employed are published elsewhere and are similar to those of other workers. ' - 6 The Olympus fiberduodenscope (jFB), a side-viewing endoscope with a cannula deflector, was used with the first 4 patients and the Olympus GIF-D forward-viewing fiberscope which lacks a cannula control lever with the last 6. The fifth patient was studied on 2 separate occasions with the GIF-D to resolve a radiologic uncertainty; the tenth was studied with both instruments at the same session.
MD MD MD MD
Portland, Oregon
case 6 (see below). The papilla was visualized en face in all, and despite the lack of a cannula deflector, was successfully cannulated in 3 patients (Figures 2, 3). One of these patients was re-endoscoped with the GIF-D and succcessfully cannulated a second time to resolve a question of interpretation of x-rays. One of the 3 failures (case 10) was re-endoscoped with the JFB at the same session and successfully cannulated. Case 6, a patient with decompensated Laennec's cirrhosis and liver tests suggesting obstruction, developed signs of perforation following a prolonged effort to negotiate a tortu-
Table I
Comparison of side-viewing and forward-viewing instruments Afferent loop No. pts. Attempts entered 4 5 4
]FB (lateral) 6 7 7 GIF-D (forward) 'Presumed retroperitoneal duodenal perforation
Papilla seen 3
7
Cannu- Complilated cations 2 0
4
l'
RESULTS Our experience is summarized in Table I. 1. Side-viewing Fiberduodenscope (JFB). In 5 procedures the afferent loop was entered in 4, the endoscope advanced to the papilla in 3 and was cannulated successfully in 2. Fluoroscopy during the procedure was not helpful in identifying the loop being entered. Previous hypotonic duodenography was used in 2 cases and was useful in predicting difficulties with a redundant afferent loop but did not otherwise facilitate the procedure. Delays and difficulties in identifying and entering the afferent loop and in introducing the instrument through the loop to the papilla of Vater were encountered with all patients. Figure 1 shows a pancreatogram made with this instrument. 2. Forward-viewing Fiberscope (GIF-D). In all 6 patients the afferent loop was easily identified, entered, ancj followed to its blind termination. There were no problems except in
Figure 1. Using the side-viewing duodenoscope, the pancreatic duct has been cannulated and visualized (lateral view), showing slight enlargement and irregularity of the ducts consistent with the patient's advanced age.
ous, fixed, afferent loop and several unsuccessful attempts to introduce a catheter into the papilla. She was explored after x-rays showed contrast agent intramurally in the duodenum, as well as retroperitoneal and free peritoneal gas. She died 24 days later in liver failure. Neither at surgery nor at postmortem examination could the site of perforation be identified. DISCUSSION When patients with gastrojejunostomy after Billroth II partial gastrectomy develop indications for ERCP, thepailla of Vater must be approached in a retrograde fashion through the afferent loop. This maneuver has been difficult in our experience with the side-viewing fiberscope routinely used for cannulation in the intact upper gastrointestinal tract. This difficulty is due in part to an optical system which
From the Departments of Medicine and Diagnostic Radiology, University of Oregon Medical School, and the Department of Medicine, Veterans Administration Hospital, Portland, Oregon. Reprint requests: Dr. Ronald M. Katon, Department of Medicine, University of Oregon Medical School, Portland, Oregon 97201. GASTROINTESTINAL ENDOSCOPY
165
peritoneal adhesions, may make the procedure more difficult and increase the risk of complications. Addendum: Since this paper was written, cannulation was successful in 2 patients with a Billroth II gastric resection using the Olympus model GIF-K.
Figure 2. The front-viewing fiberscope is in place within the afferent loop; cannula is in the pancreatic duct, both ducts are visualized. The pancreatic duct shows minor irregularity consistent with the patient's advanced age. The filling defect in the duct is an air bubble. hampers the precise placementof the tip of the instrument into a selected opening. Using blind passage, moreover, we found, as did SMrany,8 that the efferent loop was preferentially entered. Difficulty encountered in passing the instrument retrogradely through the afferent loop related to its flexibility and to its tendency to move laterally rather than forward in the intestine. This was readily apparent at fluoroscopic observation. Use of the forward-viewi ng Olympus GIF- D fi berscope over the last 3 years in the evaluation of over 200 patients with Billroth II anastomoses has impresssed us with the ease of entering and examining both efferent and afferent loops. Furthermore, in the course of these studies we have frequently seen the papilla of Vater and have noted that the position of its orifice allows an excellent en face view when approached in this retrograde fashion. This experience, coupled with the above difficulties encountered with the side-viewing instrument, suggested the trial of the Olympus GIF-D for cannulation. As noted, the afferent loop was entered and the papilla identified in all 7 attempts, and cannulation was successful in 4. In the remaining 3 cases the addition of a deflecting lever to position the cannula more precisely may have allowed cannulation. The recently developed oblique (30°) viewing fiberscope (Olympus GIF-K) is equipped with such a lever and may prove useful in studying such patients. Regardless of which instrument is used, care must be taken in traversing the afferent loop. Theprocedure should not be attempted in the immediate postoperative period when distention mayproduce a leak at the suture lines. A long afferent loop, especially one associated with fixed flexures andVOLUME 21, NO.4, 1975
Figure 3. The front-viewing fiberscope is indenting the medial duodenal wall; cannula (arrow) is in the common bile duct.
REFERENCES 1. KASUGAI T, KUNO N, KOBAYASHI S, HATTORI K: Endoscopic pancreatocholangiography: I. The normal endoscopic pancreatocholangiogram. Gastroenterology 63:217, 1972 2. OGOSHI K, NIWA M, HARA Y, NEBEL aT: Endoscopic pancreatocholangiography in the evaluation of pancreatic and biliary disease. Gastroenterology 64:210, 1973 3. COTTON PB, SALMON PR, BLUMGART LH, BURWOOD Rj, DAVIES GT, LAWRIE BW, PIERCE jW, READ AE: Cannulation of papilla of Vater via fiberduodenoscope, assessment of retrograde cholangiography in sixty patients. Lancet 1:53, 1972 4. SAFRANY L, TARI j, BARNA L, TOROK I: Endoscopic retrograde cholangiography. Gastrointestinal Endoscopy 19:163, 1973 5. VENNES jA, SILVIS SE: Endoscopic visualization of bile and pancreatic ducts. Gastrointestinal Endoscopy 18: 149, 1972 6. KATON RM, LEE TG, PARENT jA, BILBAO MK, SMITH FW: Endoscopic retrograde cholangiopancreatography (ERCP): experience with 100 cases. Arner J Dig Dis 19:295,1974 7. all: Duodenoscopyduring pancreatic disease. Arch Fr Mal App Dig 61 :349, 1972 8. SAFRANY, L: Endoscopy and retrograde cholangiopancreatography after Billroth II operation. Endoscopy 4:198,1972