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Endoscopic sphincterotomy in patients with Billroth II partial gastrectomy: comparison of three different techniques
0016-5107/84/3005-0300$02.00/0
GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy
Technical Notes Endoscopic sphincterotomy in patients with Billroth II partial gastrectomy: comparison of three different techniques G. Bedogni, MD G. Bertoni, MD S. Contini, MD F. Fabbian, MD C. Pedrazzoli, MD E. Ricci,MD
Endoscopic sphincterotomy (ES) has become a well established therapeutic procedure for the treatment of residual or recurrent stones in the common bile duct. 1, 2
a mortality of about 1%.3 Previous gastrointestinal surgery, such as a Billroth II partial gastrectomy, may make the cannulation of the papilla and the sphincterotomy technically difficult with a consequent lower success rate (50 to 80%).4 Because of the difficulty in making the incision of the papilla at the optimal position, different techniques from the standard papillotomy have been suggested. An alternative technique is to cut in the direction distal to the papillary opening using a standard papillotome\ or to use forward viewing instruments and to cut in the proximal direction with a Sohma or Ikeda-type sphincterotome5.6; or to create a choledo-
Figure 1. A, The Sohma papillotome is introduced through the papillary opening. B, ES is performed with a frontal viewing endoscope in the proximal direction.
The success rate of performing sphincterotomy and removing stones from the common bile duct averages around 90% with a complication rate of 7 to 10% and From Servizio di Endoscopias Second Divisione Chirurgica, Arcispedale S. Maria Nuova, Reggio Emilia, Italy. Reprint requests: Dr. Giuliano Bedogni, Servizio di Endoscopia, Second Divisione Chirurgica, Arcispedale S. Maria Nuova, 42100 Reggio Emilia, Italy.
300
choduodenal fistula by a needle-type diathermic cutter, introducing through the fistula the Classen-Demling papillotome and then cutting in the distal direction.? A further method of endoscopic sphincterotomy using a diathermic needle-type cutter introduced into the papillary opening and cutting in the distal direcGASTROINTESTINAL ENDOSCOPY
tion has been accomplished by us in patients with Billroth II gastrectomy. This is a modification of the technique recently described by Schapira and Khawaja8 as an alternative method of sphincterotomy in difficult anatomical situations, although not specially suggested for patients with partial gastrectomy. The purpose of this article is to report about techniques and results of endoscopic sphincterotomy in 16 patients with Billroth II partial gastrectomy. PATIENTS AND METHODS Patients
Figure 2. A, The Sohma papillotome is introduced into the papilla. B, ES is being accomplished.
During the last three years 203 endoscopic sphincterotomies have been performed in this center, mainly for recurrent or residual stones of the common bile duct in patients with previous biliary surgery. Sixteen patients (seven women and nine men), with ages from 48 to 67 years (mean age, 58), were previously submitted to a Billroth II partial gastrectomy. Nine patients had recurrent or retained stones, while in seven cases there were residual stones in the common bile duct. All of them were high risk patients and conventional surgery was refused in eleven. Stones were allowed to pass spontaneously after sphincterotomy or were extracted using a Dormia basket. A nasobiliary suction tube was always left in the common bile duct after the procedure.
Figure 3. A, The endoscope with the electrode producing the choledochoduodenal fistula. B, The papillotome is introduced through the fistula for sphincterotomy. VOLUME 30, NO.5, 1984
301
the common bile duct was cut in the distal direction (Figs. 5 and 6). RESULTS
Endoscopic sphincterotomy was successfully accomplished in all cases except one (93.7% success rate), and adequate biliary drainage was obtained. In the one case in which a pediatric endoscope was used, it was not possible to cannulate the papilla because of an extremely long afferent loop. No major complications such as bleeding or perforation were experienced. In one case only a slight and transient elevation of serum amylase was observed and treated conservatively by antibiotics with a prompt recovery. DISCUSSION
Figure 4. A, The papillotome has been introduced into the choledochoduodenal fistula and ES is being performed. B, A subsequent phase of ES. C, A nasobiliary tube has been introduced into the common bile duct.
Techniques
A pediatric endoscope with a frontal view was used in three patients, and the Sohma papillotome was introduced through the papilla of Vater into the common bile duct cutting in the proximal direction (Figs. 1 and 2). In four patients a choledochoduodenal fistula was performed according to the method of Rosseland et aJ.7 through the intraluminal part of the common bile duct. The papillotome was then introduced through the fistula for sphincterotomy in the distal direction (Figs. 3 and 4). The sphincterotomy was performed in nine patients using a side viewing duodenoscope: a needle-type diathermic cutter was introduced into the papillary opening and the wall of 302
The success rate of endoscopic cannulation of the papilla and sphincterotomy after Billroth II gastrectomy in our patients was 93.7%, without important complications and without any death. These are very gratifying results, but considering the small number of cases, general conclusions about success rate, complications, and mortality rate cannot be made. In these anatomical situations endoscopic cannulation 9 and papillotomy4, 7provide difficult technical problems which sometimes cannot be overcome, thus justifying the reported lower success rate (50 to 80%). All the techniques which have been proposed for ES in these cases were performed in our patients, except that suggested by Safrany.3 We feel in fact that with this last method the cannulation of the papilla in the correct direction might be very difficult. Moreover, there is a real threat of damage to the main pancreatic duct because of the difficulty in controlling the direction of the incision. Prograde viewing pediatric gastroscopes, which may be of value in some cases, are often too short to enter a long afferent loop, as happened in one of our cases. Also, the tip of the papillotome is far from the end of the gastroscope, having as a consequence difficult cutting control. The large caliber adult instrument may make the procedure very hard. For these reasons we found this technique more complex than the others. Rosseland et al.'s7 technique is certainly a good one, and it was used in four of our patients. There is usually no difficulty in performing the choledochoduodenal fistula, although some hazards such as retroperitoneal perforation and bleeding must be kept in mind. However, it can be troublesome to get out of the papillary opening after entering the fistula, thus making the papillotomy very difficult if not under visual control. The technique suggested by Schapira and KhawajaB as an alternative method ofES in selected and difficult cases, although not recommended for patients with a Billroth II gastrectomy, has in our opinion some advantages: the anatomical landmarks are easily found GASTROINTESTINAL ENDOSCOPY
Figure 6. The diathermic needle tip is inserted in the papilla (A) and advanced in the proximal direction toward the biliary duct (B) to complete the sphincterotomy (C).
Figure 5. A, The needle tip diathermic cutter is introduced into the papillary opening. B, The sphincterotomy has been accomplished.
VOLUME 30, NO.5, 1984
with a side viewing endoscope, and the cutting direction seems to be well controlled by the diathermic needle. It must be said, however, that perforation can always be a real risk even in the best conditions, and for this reason we support the use of a nasobiliary suction tube both for drainage and diagnostic purposes (cholangiography). In our hands, this method is more rapid and easier than the others, although some modifications to the endoscopic equipment could improve the technique. A thinner diathermic needle and better control of the metal tip coming out of the catheter could probably provide easier manipulation. 303
REFERENCES 6. 1. Cotton PB. Duodenoscopic sphincterotomy and bile duct stone retrieval. In: Bennett JR, ed. Therapeutic endoscopy and radiology of the gut. London: Chapman and Hall, 1981:169-83. 2. Demling LM, Classen M, eds. Endoscopic sphincterotomy of the papilla of Vater. Stuttgart: Thieme, 1978:48. 3. Safrany L. Endoscopic treatment of biliary tract disease. Lancet 1978;2:983-5. 4. Safrany L, Neuhaus B, Portocarrero G, Krause S. Endoscopic sphincterotomy in patients with Billroth II gastrectomy. Endoscopy 1980;12:16-22. 5. Ikeda D, Tanaka M, Itoh H, Tamura R. A newly devised cutting
Laparoscopic lysis of adhesions for postappendectomy pain Sylvain Kleinhaus, MD
Postoperative pain following appendectomy is not commonly considered in articles on appendicitis and its complications. For the most part, this pain is transient and ascribed to wound healing in a very nonspecific manner. If the symptoms persist for more than a month or two or are especially bothersome, local injection of anesthetics is sometimes successful when the pain originates in the abdominal wall proper. In other patients the pain is described as being crampy and intermittent and its source is thought to be incomplete intestinal obstruction. The latter group is usually treated expectantly despite occasionally severe symptoms. The rationale for this conservative treatment is that these patients have a form of incomplete obstruction due to local adhesions and any attempt to lyse these adhesions surgically would probably lead to other adhesions and a vicious cycle initiated. Recently two patients, who had been seen by several physicians without resolution of the symptoms or discovery of a specific etiology, were referred to us with persistent postappendectomy pain. Laparoscopy was performed as a "last resort," and in both instances pericecal adhesions were identified and lysed resulting in immediate relief of symptoms.
7. 8. 9.
probe for endoscopic sphincterotomy of the ampulla of Vater. Endoscopy 1977;9:238-41. Sohma S, Takekawa, I, Okamoto Y, Matsuda T, et al. Endoscopic papillotomy: a new approach for extraction of residual stone (in Japanese). Gastrointest Endosc 1974;16:466-71. Rosseland AR, Osnes M, Kruse A. Endoscopic sphincterotomy (EST) in patients with Billroth II gastrectomy. Endoscopy 1981;13:19-24. Schapira L, Khawaja Fl. Endoscopic fistulo-sphincterotomy: an alternative method of sphincterotomy using a new sphincterotome. Endoscopy 1982;14:58-60. Osnes M, Myren J. Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II partial gastrectomy. Endoscopy 1975;7:227-32.
admission the pain was so acute and localized to the right lower quadrant that appendectomy was performed. Microscopic examination of the appendix was not consistent with acute appendicitis. Since that time her pain had been more localized to the right lower quadrant and her internist, after multiple examinations including barium enema, upper gastrointestinal series with small bowel follow through, sonograms, and intravenous pyelograms, made the diagnosis of "spastic colon." In addition, she was found to have a form of Ehlers-Danlos syndrome. Despite his efforts, the pain persisted without improvement and she was sent to us for laparoscopy in the hope that a diagnosis could be made and treatment initiated. At laparoscopy the abdominal cavity was easily visualized. The pelvis was remarkably free of any adhesions despite the previous cesarean section, and no evidence of endometriosis was found. The cecum was suspended from the anterior abdominal wall at the level of the appendectomy scar by several adhesions. These were severed by the use of an operating scissors (Fig. 1). One year has passed since the laparoscopy and she remains symptom free.
CASE REPORTS Case 1
A 32-year-old white woman had varying degrees of intermittent lower abdominal pain for 4 years prior to admission without any relief of symptoms or exact diagnosis. The pain started soon after her last pregnancy which ended in delivery of a normal infant by cesarean section. Two years prior to From the Department of Pediatric Surgery, Albert Einstein College of Medicine-Montefiore Hospital and Medical Center, Bronx, New York. Reprint requests: Sylvain Kleinhaus, MD, Montefiore Hospital and Medical Center, 111 East 210th Street, Bronx, New York 10467. 304
Figure 1. Laparoscopic photograph showing adhesions from cecum (arrow) to anterior abdominal wall being lysed by use of operating scissors.
GASTROINTESTINAL ENDOSCOPY
GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy
Technical Notes Endoscopic sphincterotomy in patients with Billroth II partial gastrectomy: comparison of three different techniques G. Bedogni, MD G. Bertoni, MD S. Contini, MD F. Fabbian, MD C. Pedrazzoli, MD E. Ricci,MD
Endoscopic sphincterotomy (ES) has become a well established therapeutic procedure for the treatment of residual or recurrent stones in the common bile duct. 1, 2
a mortality of about 1%.3 Previous gastrointestinal surgery, such as a Billroth II partial gastrectomy, may make the cannulation of the papilla and the sphincterotomy technically difficult with a consequent lower success rate (50 to 80%).4 Because of the difficulty in making the incision of the papilla at the optimal position, different techniques from the standard papillotomy have been suggested. An alternative technique is to cut in the direction distal to the papillary opening using a standard papillotome\ or to use forward viewing instruments and to cut in the proximal direction with a Sohma or Ikeda-type sphincterotome5.6; or to create a choledo-
Figure 1. A, The Sohma papillotome is introduced through the papillary opening. B, ES is performed with a frontal viewing endoscope in the proximal direction.
The success rate of performing sphincterotomy and removing stones from the common bile duct averages around 90% with a complication rate of 7 to 10% and From Servizio di Endoscopias Second Divisione Chirurgica, Arcispedale S. Maria Nuova, Reggio Emilia, Italy. Reprint requests: Dr. Giuliano Bedogni, Servizio di Endoscopia, Second Divisione Chirurgica, Arcispedale S. Maria Nuova, 42100 Reggio Emilia, Italy.
300
choduodenal fistula by a needle-type diathermic cutter, introducing through the fistula the Classen-Demling papillotome and then cutting in the distal direction.? A further method of endoscopic sphincterotomy using a diathermic needle-type cutter introduced into the papillary opening and cutting in the distal direcGASTROINTESTINAL ENDOSCOPY
tion has been accomplished by us in patients with Billroth II gastrectomy. This is a modification of the technique recently described by Schapira and Khawaja8 as an alternative method of sphincterotomy in difficult anatomical situations, although not specially suggested for patients with partial gastrectomy. The purpose of this article is to report about techniques and results of endoscopic sphincterotomy in 16 patients with Billroth II partial gastrectomy. PATIENTS AND METHODS Patients
Figure 2. A, The Sohma papillotome is introduced into the papilla. B, ES is being accomplished.
During the last three years 203 endoscopic sphincterotomies have been performed in this center, mainly for recurrent or residual stones of the common bile duct in patients with previous biliary surgery. Sixteen patients (seven women and nine men), with ages from 48 to 67 years (mean age, 58), were previously submitted to a Billroth II partial gastrectomy. Nine patients had recurrent or retained stones, while in seven cases there were residual stones in the common bile duct. All of them were high risk patients and conventional surgery was refused in eleven. Stones were allowed to pass spontaneously after sphincterotomy or were extracted using a Dormia basket. A nasobiliary suction tube was always left in the common bile duct after the procedure.
Figure 3. A, The endoscope with the electrode producing the choledochoduodenal fistula. B, The papillotome is introduced through the fistula for sphincterotomy. VOLUME 30, NO.5, 1984
301
the common bile duct was cut in the distal direction (Figs. 5 and 6). RESULTS
Endoscopic sphincterotomy was successfully accomplished in all cases except one (93.7% success rate), and adequate biliary drainage was obtained. In the one case in which a pediatric endoscope was used, it was not possible to cannulate the papilla because of an extremely long afferent loop. No major complications such as bleeding or perforation were experienced. In one case only a slight and transient elevation of serum amylase was observed and treated conservatively by antibiotics with a prompt recovery. DISCUSSION
Figure 4. A, The papillotome has been introduced into the choledochoduodenal fistula and ES is being performed. B, A subsequent phase of ES. C, A nasobiliary tube has been introduced into the common bile duct.
Techniques
A pediatric endoscope with a frontal view was used in three patients, and the Sohma papillotome was introduced through the papilla of Vater into the common bile duct cutting in the proximal direction (Figs. 1 and 2). In four patients a choledochoduodenal fistula was performed according to the method of Rosseland et aJ.7 through the intraluminal part of the common bile duct. The papillotome was then introduced through the fistula for sphincterotomy in the distal direction (Figs. 3 and 4). The sphincterotomy was performed in nine patients using a side viewing duodenoscope: a needle-type diathermic cutter was introduced into the papillary opening and the wall of 302
The success rate of endoscopic cannulation of the papilla and sphincterotomy after Billroth II gastrectomy in our patients was 93.7%, without important complications and without any death. These are very gratifying results, but considering the small number of cases, general conclusions about success rate, complications, and mortality rate cannot be made. In these anatomical situations endoscopic cannulation 9 and papillotomy4, 7provide difficult technical problems which sometimes cannot be overcome, thus justifying the reported lower success rate (50 to 80%). All the techniques which have been proposed for ES in these cases were performed in our patients, except that suggested by Safrany.3 We feel in fact that with this last method the cannulation of the papilla in the correct direction might be very difficult. Moreover, there is a real threat of damage to the main pancreatic duct because of the difficulty in controlling the direction of the incision. Prograde viewing pediatric gastroscopes, which may be of value in some cases, are often too short to enter a long afferent loop, as happened in one of our cases. Also, the tip of the papillotome is far from the end of the gastroscope, having as a consequence difficult cutting control. The large caliber adult instrument may make the procedure very hard. For these reasons we found this technique more complex than the others. Rosseland et al.'s7 technique is certainly a good one, and it was used in four of our patients. There is usually no difficulty in performing the choledochoduodenal fistula, although some hazards such as retroperitoneal perforation and bleeding must be kept in mind. However, it can be troublesome to get out of the papillary opening after entering the fistula, thus making the papillotomy very difficult if not under visual control. The technique suggested by Schapira and KhawajaB as an alternative method ofES in selected and difficult cases, although not recommended for patients with a Billroth II gastrectomy, has in our opinion some advantages: the anatomical landmarks are easily found GASTROINTESTINAL ENDOSCOPY
Figure 6. The diathermic needle tip is inserted in the papilla (A) and advanced in the proximal direction toward the biliary duct (B) to complete the sphincterotomy (C).
Figure 5. A, The needle tip diathermic cutter is introduced into the papillary opening. B, The sphincterotomy has been accomplished.
VOLUME 30, NO.5, 1984
with a side viewing endoscope, and the cutting direction seems to be well controlled by the diathermic needle. It must be said, however, that perforation can always be a real risk even in the best conditions, and for this reason we support the use of a nasobiliary suction tube both for drainage and diagnostic purposes (cholangiography). In our hands, this method is more rapid and easier than the others, although some modifications to the endoscopic equipment could improve the technique. A thinner diathermic needle and better control of the metal tip coming out of the catheter could probably provide easier manipulation. 303
REFERENCES 6. 1. Cotton PB. Duodenoscopic sphincterotomy and bile duct stone retrieval. In: Bennett JR, ed. Therapeutic endoscopy and radiology of the gut. London: Chapman and Hall, 1981:169-83. 2. Demling LM, Classen M, eds. Endoscopic sphincterotomy of the papilla of Vater. Stuttgart: Thieme, 1978:48. 3. Safrany L. Endoscopic treatment of biliary tract disease. Lancet 1978;2:983-5. 4. Safrany L, Neuhaus B, Portocarrero G, Krause S. Endoscopic sphincterotomy in patients with Billroth II gastrectomy. Endoscopy 1980;12:16-22. 5. Ikeda D, Tanaka M, Itoh H, Tamura R. A newly devised cutting
Laparoscopic lysis of adhesions for postappendectomy pain Sylvain Kleinhaus, MD
Postoperative pain following appendectomy is not commonly considered in articles on appendicitis and its complications. For the most part, this pain is transient and ascribed to wound healing in a very nonspecific manner. If the symptoms persist for more than a month or two or are especially bothersome, local injection of anesthetics is sometimes successful when the pain originates in the abdominal wall proper. In other patients the pain is described as being crampy and intermittent and its source is thought to be incomplete intestinal obstruction. The latter group is usually treated expectantly despite occasionally severe symptoms. The rationale for this conservative treatment is that these patients have a form of incomplete obstruction due to local adhesions and any attempt to lyse these adhesions surgically would probably lead to other adhesions and a vicious cycle initiated. Recently two patients, who had been seen by several physicians without resolution of the symptoms or discovery of a specific etiology, were referred to us with persistent postappendectomy pain. Laparoscopy was performed as a "last resort," and in both instances pericecal adhesions were identified and lysed resulting in immediate relief of symptoms.
7. 8. 9.
probe for endoscopic sphincterotomy of the ampulla of Vater. Endoscopy 1977;9:238-41. Sohma S, Takekawa, I, Okamoto Y, Matsuda T, et al. Endoscopic papillotomy: a new approach for extraction of residual stone (in Japanese). Gastrointest Endosc 1974;16:466-71. Rosseland AR, Osnes M, Kruse A. Endoscopic sphincterotomy (EST) in patients with Billroth II gastrectomy. Endoscopy 1981;13:19-24. Schapira L, Khawaja Fl. Endoscopic fistulo-sphincterotomy: an alternative method of sphincterotomy using a new sphincterotome. Endoscopy 1982;14:58-60. Osnes M, Myren J. Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II partial gastrectomy. Endoscopy 1975;7:227-32.
admission the pain was so acute and localized to the right lower quadrant that appendectomy was performed. Microscopic examination of the appendix was not consistent with acute appendicitis. Since that time her pain had been more localized to the right lower quadrant and her internist, after multiple examinations including barium enema, upper gastrointestinal series with small bowel follow through, sonograms, and intravenous pyelograms, made the diagnosis of "spastic colon." In addition, she was found to have a form of Ehlers-Danlos syndrome. Despite his efforts, the pain persisted without improvement and she was sent to us for laparoscopy in the hope that a diagnosis could be made and treatment initiated. At laparoscopy the abdominal cavity was easily visualized. The pelvis was remarkably free of any adhesions despite the previous cesarean section, and no evidence of endometriosis was found. The cecum was suspended from the anterior abdominal wall at the level of the appendectomy scar by several adhesions. These were severed by the use of an operating scissors (Fig. 1). One year has passed since the laparoscopy and she remains symptom free.
CASE REPORTS Case 1
A 32-year-old white woman had varying degrees of intermittent lower abdominal pain for 4 years prior to admission without any relief of symptoms or exact diagnosis. The pain started soon after her last pregnancy which ended in delivery of a normal infant by cesarean section. Two years prior to From the Department of Pediatric Surgery, Albert Einstein College of Medicine-Montefiore Hospital and Medical Center, Bronx, New York. Reprint requests: Sylvain Kleinhaus, MD, Montefiore Hospital and Medical Center, 111 East 210th Street, Bronx, New York 10467. 304
Figure 1. Laparoscopic photograph showing adhesions from cecum (arrow) to anterior abdominal wall being lysed by use of operating scissors.
GASTROINTESTINAL ENDOSCOPY