Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography for the Treatment of Common Bile Duct Stones in Patients with Roux-en-Y Gastrectomy: Outcomes and Factors Affecting Complete Stone Extraction

Taisuke Obata,Yuki Fujii,Hironari Kato,Toru Ueki,Ryuta Takenaka,Hiroyuki Okada,Tatsuhiro Yamazaki,Kazuyuki Matsumoto,Kengo Yasugi,Akihiro Matsumi,Kazuya Miyamoto,Tsuneyoshi Ogawa,Koichiro Tsutsumi,Shigeru Horiguchi

doi:10.3390/jcm10153314

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in patients with Roux-en-Y gastrectomy (RYG) remains technically challenging. Methods: Seventy-nine RYG patients (median 79 years old) underwent short-type double-balloon enteroscopy-assisted ERCP (sDBE-ERCP) for CBD stones at three referral hospitals from 2011–2020. We retrospectively investigated the treatment outcomes and potential factors affecting complete stone extraction. Results: The initial success rates of reaching the papilla of Vater, biliary cannulation, and biliary intervention, including complete stone extraction or biliary stent placement, were 92%, 81%, and 78%, respectively. Of 57 patients with attempted stone extraction, complete stone extraction was successful in 74% for the first session and ultimately in 88%. The adverse events rate was 5%. The multivariate analysis indicated that the largest CBD diameter ≥ 14 mm (odds ratio (OR), 0.04; 95% confidence interval (CI), 0.01–0.58; p = 0.018) and retroflex position (OR, 6.43; 95% CI, 1.12–36.81; p = 0.037) were independent predictive factors affecting complete stone extraction achievement. Conclusions: Therapeutic sDBE-ERCP for CBD stones in a relatively elderly RYG cohort, was effective and safe. A larger CBD diameter negatively affected complete stone extraction, but using the retroflex position may be useful for achieving complete stone clearance.

Highlights

For common bile duct (CBD) stones in Roux-en-Y gastrectomy (RYG) patients treated at three tertiary institutions
Initial biliary intervention, including complete stone extraction or biliary stent placement, was successful in 78% (62/79), complete stone extraction was initially achieved in 53% (42/79) and in 63% (50/79), and adverse events occurred in 5% (5/79)
Successfully reaching the papilla has been reported in 92% (54/59) of Billroth-II patients but only 33–67% of RYG patients

Summary

Introduction

Cholelithiasis is an adverse event in patients with surgically altered anatomies due to a history of gastrectomies, such as Billroth-II reconstruction and Roux-en-Y (R-Y) anastomosis [1,2,3]. Since common bile duct (CBD) stones often cause patients life-threatening severe cholangitis and pancreatitis, biliary intervention, such as stone extraction or biliary drainage, is required [4,5]. Endoscopic treatment of CBD stones via the papilla of Vater is technically challenging, especially in patients who have undergone R-Y gastrectomy (RYG), due to the difficulty of reaching the papilla and performing biliary cannulation or ampullary procedures or stone extraction [6,7,8,9,10], compared to those with normal anatomy. Percutaneous transhepatic intervention or surgery is often performed as an alternative treatment [11,12,13,14]

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Results

Conclusion