Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction

INTRODUCTION — Billroth II reconstruction is one option to restore gastrointestinal continuity following partial gastrectomy (figure 1). Partial gastrectomy with reconstruction can be performed to treat adverse events of peptic ulcer disease (such as perforation, bleeding, and duodenal stricture) or gastric carcinoma localized at the antrum. This reconstruction technique was named after Theodor Billroth, who first performed it in January 1885. Although less often performed for adverse events of peptic ulcer disease because of changes in management (H2 blockers and proton pump inhibitors), the Billroth II operation remains a surgical option for reconstruction after distal stomach resection. (See "Partial gastrectomy and gastrointestinal reconstruction", section on 'Gastrointestinal reconstruction' and "Total gastrectomy and gastrointestinal reconstruction", section on 'Gastrointestinal reconstruction'.)

Because of the surgically altered anatomy, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is more difficult in patients with previous Billroth II gastrectomy compared with patients with native anatomy. The region of the major and minor papilla in the second part of the duodenum can only be reached through the afferent loop. As a result, the papilla of Vater appears upside-down when compared to its orientation during standard ERCP (figure 1).

Performing ERCP in a patient with Billroth II anatomy involves the following:

●Choosing the appropriate endoscope

●Entering the afferent loop

●Reaching the duodenal stump

●Cannulating the papilla from a reverse position

●Performing an endoscopic sphincterotomy

These issues will be discussed here. ERCP in patients with Roux-en-Y anatomy is discussed separately. (See "ERCP in patients with Roux-en-Y anatomy".)

Indications for and adverse events associated with ERCP are discussed separately:

●(See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

●(See "Post-ERCP perforation".)

●(See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding".)

●(See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)

ANATOMY — The Billroth II anastomosis is created after the proximal stomach is transected at the antrum and the duodenum is divided distal to the pyloric ring. One of two techniques is then used to reconstruct the anatomy (figure 1):

●The Hofmeister technique, in which the half of the gastric resection line closest to the lesser curvature is sutured, and the lower half (ie, closest to the greater curvature) is anastomosed to the proximal jejunum.

●The Polya technique, in which the gastrojejunal anastomosis includes the entire length of the gastric resection line.

In both techniques, the afferent and efferent jejunal limbs can be separated by a wide or a narrow distance, depending upon the size of the stoma. The position of the efferent and afferent limbs relative to one another can be highly variable.

SELECTING AN ENDOSCOPE

Forward-viewing versus side-viewing endoscopes — Some advanced endoscopists advocate the routine use of a forward-viewing endoscope (eg, gastroscope or a pediatric colonoscope) to manage long afferent loops during ERCP [1]. The major drawback of forward-viewing endoscopes is the lack of an elevator mechanism at the operative channel once the papillary area has been reached. Other experts use a side-viewing duodenoscope initially for performing ERCP in patients with Billroth II anatomy [2], and they switch to a forward-viewing endoscope if the duodenoscope is not successful [3].

Data on rates of intubation, biliary cannulation, and adverse events are mostly from retrospective or observational studies [1,4,5]. In a systematic review of 11 studies including 499 patients with Billroth II gastrectomy who underwent ERCP with a forward-viewing endoscope, the rates for afferent loop intubation and selective cannulation were 90 and 91 percent, respectively, while the rates of bowel perforation and pancreatitis were 3 and 5 percent, respectively [5]. In a systematic review of 16 studies including 1947 patients with Billroth II gastrectomy who underwent ERCP with a side-viewing endoscope, the rates for afferent loop intubation and selective cannulation were 87 and 92 percent, respectively, while the rates of bowel perforation and pancreatitis were 4 and 3 percent, respectively [5]. (See "Post-ERCP perforation".)

Outcomes of ERCP in 713 patients with Billroth II anatomy who underwent 1050 ERCPs were examined in a report from the Catholic University in Rome [3]. The ERCPs were initiated with a side-viewing endoscope, while a forward-viewing endoscope was used only if the side-viewing endoscope was unsuccessful. Overall, successful duodenal intubation was accomplished in 87 percent of procedures. When the duodenal stump was successfully intubated, biliary or pancreatic duct cannulation was successful in 94 percent of cases. There were 22 perforations (2 percent of procedures; 3 percent of patients). Two patients died because of adverse events related to jejunal perforation (0.3 percent).

Cap-assisted ERCP with a forward-viewing endoscope has been reported as an option when a side-viewing duodenoscope or an uncapped gastroscope were unsuccessful (picture 1) [6-8]. Based on clinical experience, cap-assisted ERCP may be performed using a therapeutic gastroscope (3.7 mm working channel) or a pediatric colonoscope (3.7 mm working channel).

Other endoscopes

●Enteroscopes – Intubation of the duodenal stump using a forward- or side-viewing endoscope may occasionally be impossible in patients with a relatively long afferent loop. An increasing number of case reports have described success using balloon-assisted enteroscopy in patients with Billroth II gastrectomy or Roux-en-Y anastomosis. However, experience is limited, and the necessary equipment (including a long ERCP catheter) is not widely available. Short-type enteroscopes have been developed, and both short double-balloon and short single-balloon enteroscopy are suitable for ERCP. A short-type double-balloon enteroscope has a 2.8 mm working channel and a 152 cm working length. The advantage of this device is that it can accommodate most ERCP accessories [9]. In addition, a short single-balloon enteroscope with a wider channel (ie, 3.2 mm) is also available [10]. According to reports, these short enteroscopes appear safe and effective for use in ERCP [11,12]. (See "Overview of deep small bowel enteroscopy".)

●Oblique-viewing endoscope (not commercially available in some countries) – Some endoscopists have suggested that the ideal instrument for ERCP in patients with surgically altered anatomy would blend the best features of both the forward-viewing endoscope and the side-viewing duodenoscope, including an elevator and an angle of view that is a compromise between the two instruments [13]. Some reports appear to support the use of an oblique-viewing endoscope in patients with Billroth II gastrectomy or Roux-en-Y reconstruction [14-17].

TECHNIQUE — Performing an ERCP in patients with Billroth II anatomy requires that the afferent loop be identified and entered, that the duodenal stump be reached, and that the desired duct be successfully cannulated. In many cases, an endoscopic sphincterotomy is also performed.

Entering the afferent loop — The first problem to be solved when attempting ERCP in patients with Billroth II anatomy is identification of the afferent loop at the site of the gastrojejunostomy. The loop adjacent to the lesser curve is usually examined first since it is more likely to lead to the afferent loop. However, fluoroscopy is often more accurate in showing the direction toward the right hypochondrium.

Entering the afferent loop is sometimes extremely difficult, especially when the lesser curve remnant is short and the anastomosed loop is angled. When using a side-viewing duodenoscope, the endoscopic procedure is usually started with the patient lying in the left lateral position. However, turning the patient to the supine or prone position may improve the axis and facilitate introduction of the scope into the stoma.

If these maneuvers are unsuccessful, the stoma can be cannulated with a J-tipped Teflon-coated or stiff hydromer-coated guidewire that is subsequently made rigid using a 10 French biliary bougie-type dilator (Soehendra dilator). The scope can then be pushed over the bougie, which acts as a straightener. When performing these complex maneuvers, we use fluoroscopic imaging for additional guidance.

Another useful technique for safely entering the appropriate loop using a side-viewing duodenoscope is retrieval balloon-assisted enterography [16]. The guidewire of the retrieval balloon is advanced to the appropriate limb, and then a retrieval balloon is inserted over the guidewire. Following injection of contrast agent, the target limb is radiologically explored. Then the balloon is hooked to the limb, and while the balloon catheter is retracted into the working channel, the scope can advance.

Reaching the duodenal stump — The technique of scope progression into the afferent loop closely resembles techniques used during colonoscopy. One or more straightening maneuvers are often necessary to manage long loops and to obtain a better working position when the tip of the scope faces the papillary area. Straightening maneuvers may occasionally employ a clockwise or counterclockwise rotation of 360 degrees that requires detaching the scope insertion from the video-processor to avoid a complete loop on the scope light-cable. Having the scope in the "short" position (straightened scope) allows precise maneuvers during attempts at cannulation.

Based on clinical experience, moving the patient to the supine position often facilitates advancing the scope into the afferent loop because it allows more precise radiologic orientation. In addition, infusion of contrast into the jejunal loop by air insufflation or by contrast injection through the operative channel helps to define the bowel anatomy when acute angles hinder progression of the scope. The supine position also permits hand compression over the abdomen to reduce loops formed by the endoscope.

Some data suggest that the use of a cap-fitted, forward-viewing endoscope could be a major advantage for afferent loop identification, intubation of the duodenal stump, and duct cannulation [7,8,18,19]. The cap could provide a fixed distance between the jejunal wall and the tip of the endoscope, and thus improve the identification of sharp angulations. It also displaces the jejunal folds during the progression of the endoscope and reduces the need for air inflation and, consequently, loop formation. Furthermore, the cap could help biliary cannulation by fixing the tip of the endoscope in the appropriate position in front of the papilla (picture 1) [18,19].

Cannulating the papilla from the reverse position — With the side-viewing duodenoscope, the papilla of Vater appears in a completely reverse position to its orientation during standard ERCP (picture 2). Cannulation and injection of the pancreatic duct is usually not a major problem because the duct joins the duodenum at a favorable angle. However, bile duct cannulation is more challenging.

Since the majority of cannulas tend to assume an upward curve, most experts use a straight catheter to improve the axis toward the biliary direction (ie, 5 to 6 o'clock, which is the opposite of the routine position in patients with unaltered gastroduodenal anatomy). The biliary orientation of the catheter may be further increased by slightly pulling back the duodenoscope, bending the tip of the duodenoscope toward the duodenal wall, and pushing the catheter while keeping its tip in contact with the papillary orifice.

Another approach for cannulating the papilla from the reverse position involves the use of a rotatable sphincterotome. In a study including 86 patients with Billroth II gastrectomy who underwent ERCP, use of a rotatable sphincterotome was associated with higher rates of successful biliary cannulation and sphincterotomy compared with a conventional sphincterotome (88 versus 24 percent and 90 versus 28 percent, respectively) [20].

It is sometimes useful to modify the tip of the catheter by bending the distal part into a sigmoid shape. Directing the catheter tip toward the 5 to 6 o’clock position facilitates selective biliary cannulation. Every manipulation of the catheter should be carefully monitored with fluoroscopy, which is often much more helpful than the endoscopic view. When the papilla is close to or within a duodenal "cul-de-sac," cannulation may be more demanding or sometimes impossible. Other anatomic abnormalities such as parapapillary diverticula may hinder cannulation as in the patient with native anatomy.

As discussed above, a side-viewing duodenoscope with an elevator is a major advantage in this phase of the procedure. Compared with the forward-viewing scope, it permits much more precise manipulation of catheters.

Endoscopic sphincterotomy — Many techniques have been proposed for performing endoscopic sphincterotomy in patients with Billroth II anatomy. As mentioned above, the main technical problem is due to the reverse position of the papilla in the endoscopic field. Because of this, the wire of the sphincterotome should cut, ideally, in a 5 to 6 o'clock direction. An inverted sphincterotome with a long distal tip was designed so that the cutting wire is oriented towards the 6 o'clock rather than the 12 o'clock position (picture 3) [3,21]

Use of a sphincterotome requires deep cannulation of the common bile duct, which guarantees the sphincterotomy to be as safe as possible, provided it is correctly directed. However, most sphincterotomes have proved difficult to orient properly during routine use. As a result, some endoscopists use a needle knife to carry out a complete "freehand" cutting of the papillary roof [22]. This method, although simple and effective in expert hands, does not meet any of the safety criteria accepted for patients without gastrectomy, particularly since it does not require deep cannulation of the common bile duct. (See "Management of difficult biliary access during ERCP in adults".)

The "freehand" technique was later replaced by the "over-the-stent" needle knife technique [23]. This modification offers the advantage of a controlled cutting direction, thanks to a previously inserted biliary stent, and is widely used in this setting [24]. Nevertheless, both techniques probably carry a higher risk of retroperitoneal perforation [25].

Balloon dilation of the papilla ("sphincteroplasty") has also been suggested as an alternative technique to avoid technical problems of endoscopic sphincterotomy in patients with Billroth II anatomy [7,8,26-28]. (See "Endoscopic balloon dilation for removal of bile duct stones".)

Therapeutic maneuvers that can be performed in the patient with unaltered gastroduodenal anatomy, such as stone extraction, drain insertion, and stent placement, are also feasible in patients with Billroth II anatomy once access to the bile duct has been obtained via endoscopic sphincterotomy or sphincteroplasty. Use of balloon dilation in conjunction with limited sphincterotomy can permit effective and safe management of patients with difficult, large bile duct stones, rather than relying on sphincterotomy alone [29,30]. All of these procedures should be performed by highly experienced endoscopists [31].

One study evaluated the efficacy and safety of endoscopic papillary balloon dilation using a cap-fitted forward-viewing endoscope in 36 patients (44 ERCP procedures) with Billroth II gastrectomy [7]. Selective bile duct cannulation was performed in 32 patients (89 percent). Papillary balloon dilation was performed in all 32 patients, and additional endoscopic sphincterotomy was performed in four patients. Cardiovascular adverse events with transient hypoxia occurred in two patients, and perforations were observed in three patients (8.3 percent). Out of the three perforations, two were type III (ductal injury) and one was type IV (retroperitoneal air without symptoms), and one patient needed surgical treatment.

The records of 165 patients with Billroth II gastrectomy who underwent ERCP using a cap-fitted, forward-viewing endoscope with endoscopic papillary balloon dilation were retrospectively reviewed. Adverse events occurred in 16 patients (9.7 percent): perforation in three patients (1.8 percent) and pancreatitis in 13 patients (7.9 percent). In multivariable analysis, >2 ERCP sessions and a common bile duct stone size >12 mm were associated with risk of ERCP-related adverse events [8].

In another study, 77 patients with Billroth II anatomy underwent a total of 92 ERCPs with a double-balloon enteroscope, and 48 patients with common bile duct stones underwent therapy with endoscopic papillary large balloon dilation [28]. The overall rate of reaching the papilla was 95 percent (73 of 77 patients), and the treatment success rate was 92 percent (67 of 73 patients). The complication rate was 6.5 percent (5 of 77 patients): three perforations and two intestinal mucosal tears related to enteroscope/overtube use.

Pancreatic sphincterotomy has been performed safely in the setting of various pancreatic diseases (mainly chronic pancreatitis) in patients with Billroth II anatomy by adapting the technique to the modified endoscopic view and following the same principles as for biliary sphincterotomy [3].

OUTCOMES — Historically, the success rate for cannulating the desired duct (bile duct or pancreatic duct) in patients with surgically-altered anatomy was approximately 50 percent, while the overall success rate for selective cannulation was approximately 90 percent in patients with normal anatomy [32]. The ERCP success rate has improved as a result of the available instruments, accessories, and techniques [12]. In a systematic review of 43 studies including 2669 patients with Billroth II gastrectomy, there were 1432 cases (56 percent) of side-viewing endoscopy, 664 (26 percent) cases of forward-viewing endoscopy, 171 (7 percent) cases of balloon-assisted enteroscopy, 169 (7 percent) cases of anterior oblique-viewing endoscopy, 64 (3 percent) cases of dual-lumen endoscopy, 31 (1 percent) cases of colonoscopy, and 14 (0.5 percent) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91 percent, and the overall success rate of selective cannulation was 88 percent. Adverse events were reported in 195 cases (7 percent). The rate of bowel perforation was slightly higher in side-viewing endoscopy (4 percent) and balloon-assisted enteroscopy (4 percent) compared with forward-viewing endoscopy (2 percent) and anterior oblique-viewing endoscopy (1 percent). The overall mortality rate was low (0.3 percent), and deaths were reported only in procedures using side-viewing endoscopy [33].

When cannulation is not successful using the available endoscopic techniques, repeated attempts may increase the risk of adverse events including small bowel perforation [11]. For patients in whom ERCP is not successful, alternative approaches for establishing bile duct access include percutaneous or surgical intervention. (See "Management of difficult biliary access during ERCP in adults".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endoscopic retrograde cholangiopancreatography (ERCP)".)

SUMMARY AND RECOMMENDATIONS

●Background – The Billroth II operation entails partial gastrectomy with end-to-side gastrojejunostomy (figure 2). It has been performed to treat adverse events of peptic ulcer disease (such as perforation, bleeding, and duodenal stricture) or gastric carcinoma localized at the antrum. (See 'Introduction' above.)

Because of the surgically altered anatomy, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is more difficult in patients with previous Billroth II gastrectomy than in patients with native anatomy. The papillary area in the second part of the duodenum can only be reached through the afferent loop. As a result, the papilla of Vater appears upside-down compared with its orientation during standard ERCP.

●Technique – Performing an ERCP in patients with Billroth II anatomy requires that the afferent loop be identified and entered, that the duodenal stump be reached, and that the papilla be cannulated. In many cases an endoscopic sphincterotomy is also performed. (See 'Technique' above.)

Therapeutic maneuvers such as stone extraction, drain insertion, and stent placement are feasible in patients with Billroth II anatomy once access to the bile duct has been obtained via endoscopic sphincterotomy or sphincteroplasty. All of these procedures should be performed by experienced endoscopists. (See 'Technique' above.)

●Adverse events – Billroth II anatomy can increase the risk of adverse events. Perforation occurs more frequently in patients with Billroth II anatomy compared with patients with normal anatomy. (See 'Selecting an endoscope' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Silvano Loperfido, MD, who contributed to earlier versions of this topic review.