Endoscopic Papillary Large-Balloon Dilatation in Patients with Billroth II Gastrectomy

Abstract

Endoscopic sphincterotomy (ES), introduced by Classen et al. [1] as a minimally invasive technique to retrieve common bile duct (CBD) stones in high-surgical-risk patients, has become the foundation of endoscopic therapy for patients with biliary disease, with a *90 % rate of successfully removing CBD stones with basket extraction or balloon sweeping. As an alternative to ES, Staritz et al. [2] described in 1983 endoscopic papillary balloon dilatation (EPBD) with the aim of avoiding complications associated with ES in the short term such as pancreatitis, perforation, bleeding, and infection, or in the long term such as papillary stenosis and bacterial biliary contamination. EPBD is effective for the treatment of CBD stones with retrieval rates of 80–100 % [3]. The efficacy of ES and EPBD in the removal of CBD stones has been compared with multiple prospective studies and with at least two recent meta-analyses [4, 5], which have concluded that EPBD is associated with lower rates of bleeding and perforation than ES [3–6] but with a higher rate of pancreatitis [4, 5, 7, 8]. Moreover, EPBD is also associated with a lower retrieval rate of CBD stones [4, 5] which, combined with higher rates of pancreatitis, are the main reasons why most endoscopists choose ES over EPBD for CBD stone extraction. Thus, EPBD has become second line, mainly used for endoscopic treatment of CBD stones in patients with liver cirrhosis or coagulopathy. Ten years ago, one single-center retrospective study reported that ES followed by endoscopic papillary largeballoon dilation (EPLBD) of the papillary orifice (10–20 mm) improved the extraction rate of large CBD stones [9]. Further studies confirmed that ES followed by EPLBD is an effective and safe technique for retrieving large CBD stones after failure of common extraction techniques using balloon or basket [10–12]. EPLBD performed after ES effectively removed up to 87–95 % of large CBD stones in patients after the failure of balloon or basket extraction attempts [9–11]. EPLBD could also minimize the chances of pancreatitis since the existing sphincterotomy enables the dilation to proceed upward rather than circumferentially [10]. The most common complication described with this technique is bleeding that occurs in 8.3 % of patients. EPLBD after ES has also been successfully used for extraction of large CBD stones in patients with Billroth II gastrectomy [13]. ES in Billroth II gastrectomy patients is more difficult than in patients with normal anatomy due to the need for the inverted papillary approach despite the development of specific sphincterotomes. Thus, EPBD may be particularly suited for Billroth II gastrectomy patients, although the previously mentioned limitations restrict its utility. Since EPLBD alone is effective and safe in patients with normal anatomy [14], performing EPLBD without previous ES in patients with Billroth II gastrectomy is the next challenge. The outcomes of this procedure in 40 patients are described in this issue of Digestive Diseases and Sciences [15]. Jang et al. performed EPLBD alone to treat patients following Billroth II gastrectomy with difficult-toextract CBD stones. Fourteen patients with four or more J. J. Vila Endoscopy Unit, Complejo Hospitalario de Navarra, Pamplona, Spain e-mail: juanjvila@gmail.com