Therapeutic Endoscopic Retrograde Cholangiopancreaticography (ERCP) for Bile Duct Stones in Patients with a Prior Billroth II Gastrectomy

Abstract

Background and Aim: Recently, endoscopic treatment of bile duct stones in patients with a prior Billroth II gastrectomy is increasing. We evaluated the usefulness and safety of therapeutic ERCP for bile duct stones in patients who had undergone a prior Billroth II gastrectomy. Patients and methods: 30 patients with bile duct stones after Billroth II gastrectomy (20 men, 10 women; median age, 76.4 years; range, 58-93) who underwent therapeutic ERCP from January 1998 to October 2006 at our center were included in this study. The average number of bile duct stones was 2.5 (1-15) and their mean diameter was 12.0 mm (4-20). Success rates of access to the papilla of Vater and selective cannulation of the bile duct, complete stone removal ratio, and incidence of complications were evaluated. For evaluation of the incidence of complications, 550 patients without gastrectomy who underwent ERCP and endoscopic sphincterotomy (EST) for bile duct stones in the same period were studied as a control. Front oblique-viewing endoscopes (GIF XK 200,240; Olympus) we used for procedures. Results: Access to the papilla of Vater was successful in 86.7% (26/30) of the patients. As to the other four patients, two underwent surgical treatment, one underwent PTCS with complete stone removal, and the remaining patient did not receive, additional treatment due to advanced age and poor general condition. Selective cannulation of the bile duct was achieved in 96.2% (25/26) of the patients with successful access to the papilla of Vater. One in whom deep cannulation of the bile duct was not achieved underwent surgical treatment. Among the patients in whom the approach to the papilla of Vater was successful, the complete stone removal ratio was 84.6% (22/26). Because of his poor general status and advanced age, one patient did not undergo stone removal and was treated only by endoscopic biliary drainage. The ratio of complete stone removal was 95% (20/21) by EST and 67% (2/3) by EPBD. Two patients without complete stone removal underwent surgical treatment. The incidence of complications was 3.3% (1/30) in the patients with a prior Billroth II gastrectomy and 6.5% (43/662) in the control group (n.s.). One patient with prior Billroth II gastrectomy suffered from acute cholecystitis and was treated by PTGBD. Neither pancreatitis, bleeding, nor perforation was seen in the patients with a prior Billroth II gastrectomy. Conclusions: The safety of therapeutic ERCP for removal of bile duct stones in patients with a prior Billroth II gastrectomy is comparable to that in patients with normal anatomy. Improvement of the rate of complete stone removal is necessary to avoid additional surgery.