Endoscopic Retrograde Cholangiopancreatography Cannulation Research Articles

Single-session endosonography and endoscopic retrograde cholangiopancreatography for biliopancreatic diseases is feasible, effective and cost beneficial

Endoscopic ultrasonography (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) are often required in patients with pancreaticobiliary disorders. To assess the clinical impact and costs savings of a single session EUS-ERCP. Patient and intervention data from April 2009 to March 2012 were prospectively recruited and retrospectively analyzed from a database at a tertiary hospital. Indications, diagnostic yield, procedure details, complications and costs were evaluated. Fifty-five scheduled combined procedures were done in 53 patients. The accuracy of EUS-fine needle aspiration for malignancy was 90%. The main clinical indication was a malignant obstructing lesion (66%). The ERCP cannulation was successful in 67%, and in 11/15 failed ERCP (73%), drainage was completed thanks to an EUS-guided biliary drainage: 6 transmurals, 5 rendezvous. Eight patients (14%) had related complications: bacteremia (n = 3), pancreatitis (n = 2), bleeding (n = 2) and perforation (n = 1). The mean duration was 65 ± 22.2 min. The mean estimated cost for a single session was €3437, and €4095 for two separate sessions. The estimated cost savings using a single-session strategy was €658 per patient, representing a total savings of €36,189. Combined EUS and ERCP is safe, technically feasible and cost beneficial. Furthermore, in failed ERCP cases, the endoscopic biliary drainage can be completed with EUS-guided biliary access in the same procedure.

Endoscopic retrograde cholangiopancreatography with rendezvous cannulation reduces pancreatic injury

To examine whether rendezvous endoscopic retrograde cholangiopancreatography (ERCP) is associated with less pancreatic damage, measured as leakage of proenzymes, than conventional ERCP. Patients (n = 122) with symptomatic gallstone disease, intact papilla and no ongoing inflammation, were prospectively enrolled in this case-control designed study. Eighty-one patients were subjected to laparoscopic cholecystectomy and if intraoperative cholangiography suggested common bile duct stones (CBDS), rendezvous ERCP was performed intraoperatively (n = 40). Patients with a negative cholangiogram constituted the control group (n = 41). Another 41 patients with CBDS, not subjected to surgery, underwent conventional ERCP. Pancreatic proenzymes, procarboxypeptidase B and trypsinogen-2 levels in plasma, were analysed at 0, 4, 8 and 24 h. The proenzymes were determined in-house with a double-antibody enzyme linked immunosorbent assay. Pancreatic amylase was measured by an enzymatic colourimetric modular analyser with the manufacturer's reagents. All samples were blinded at analysis. Post ERCP pancreatitis (PEP) occurred in 3/41 (7%) of the patients cannulated with conventional ERCP and none in the rendezvous group. Increased serum levels indicating pancreatic leakage were significantly higher in the conventional ERCP group compared with the rendezvous ERCP group regarding pancreatic amylase levels in the 4- and 8-h samples (P = 0.0015; P = 0.03), procarboxypeptidase B in the 4- and 8-h samples (P < 0.0001; P < 0.0001) and trypsinogen-2 in the 24-hour samples (P = 0.03). No differences in these markers were observed in patients treated with rendezvous cannulation technique compared with patients that underwent cholecystectomy alone (control group). Post procedural concentrations of pancreatic amylase and procarboxypeptidase B were significantly correlated with pancreatic duct cannulation and opacification. Rendezvous ERCP reduces pancreatic enzyme leakage compared with conventional ERCP cannulation technique. Thus, laparo-endoscopic technique can be recommended with the ambition to minimise the risk for post ERCP pancreatitis.

Angled- or straight-tipped hydrophilic guidewire in biliary cannulation: a prospective, randomized, controlled trial

Deep biliary cannulation is the key for successful endoscopic retrograde cholangiopancreatography (ERCP) procedures. Guidewire-assisted cannulation is associated both with a higher success rate and a reduced risk of post-ERCP pancreatitis compared with standard catheter cannulation. However, to our knowledge there are no prospective, randomized studies comparing the use of different guidewires in biliary cannulation. The goal of this study was to compare the performance of an angled-tipped guidewire (AGW) with a straight-tipped guidewire (SGW) in achieving successful deep biliary cannulation. Patients with intended biliary cannulation of an intact papilla were prospectively randomized to angled- or straight-tipped hydrophilic guidewire arms in a tertiary, referral, university hospital setting. Randomized cannulation method was applied either until successful cannulation of the bile duct or until 2 min had passed. Crossover was not included in the study protocol. The main outcome measurements were the cannulation success rate and duration of cannulation. Of the 239 consecutive patients, 155 patients were randomized: in the final analysis 70 patients were included in the AGW arm and 83 patients in the SGW arm. Cannulation time [median; seconds (s)] was shorter with the AGW compared with the SGW (20 vs. 63 s, p = 0.01). There was no difference in the cannulation success rate or the complication rate between the two study groups. AGW may facilitate biliary cannulation in ERCP.

Laparoscopic Antegrade Biliary Stenting to Guide Biliary Cannulation in Postoperative ERCP for Ductal Stone Clearance

Purpose: The success rate of biliary cannulation is high but still not perfect in endoscopic retrograde cholangiopancreatography (ERCP). Options in these cases have traditionally included percutaneous access, open surgical intervention, and more recently a combination of either percutaneous biliary access or endoscopic ultrasonography with ERCP approach (i.e., rendezvous procedure). A laparoscopic antegrade biliary stenting has been described for biliary stone clearance. We are reporting a case that used antegrade biliary stenting during laparoscopic cholecystectomy to assist in endoscopic biliary access after a failed ERCP. Case history: The patient is a 69-year-old female who presented with worsening intermittent right upper quadrant abdominal pain for 3 weeks. The work up showed that her AST 89 (UL), ALT 277 (UL), Alkaline Phosphatase 278 (UL), and bilirubin of 1 (mg/dL). Abdominal ultrasound showed dilated common bile duct (CBD) to 12 mm and multiple gallstones. The patient underwent outpatient ERCP. The papilla looked traumatized. Cannulation was unsuccessful using sphinctertome and needle-knife. She came to ER 3 days later prior to her scheduled cholecystectomy with increased abdominal pain and elevated bilirubin. A standard cholecystectomy was performed laparoscopically. Intra-operatively, a biliary balloon catheter (Karlan balloon catheter: 4 French, 60 cm) was inserted into the cystic duct and cholangiogram was performed. The CBD was found to be dilated with large stone impacted at the ampulla. Using balloon sweep a dozen of very small stones were removed through the cystic duct, however, the large stone could not be removed. Attempt to pass basket was unsuccessful due to stricture within the cystic duct. The catheter was passed down through the cystic duct and CBD into the duodenum and the position was confirmed with fluoroscopy. This catheter was then cut at the cystic duct and left in CBD. Three clips were then placed proximally on the cystic duct and the gallbladder was then resected. Next day an ERCP was performed. The catheter was seen traversing the ampulla to duodenum. A sphinctertome with guide wire was used and the CBD was easily cannulated alongside Karlan cathter. A large sphincterotomy was performed. 1 cm biliary stone was then extracted from CBD using extraction balloon catheter. The Karlan catheter was then retrieved using a snare. The patient was discharged the following day. Conclusion: Antegrade biliary stenting during lapascopic cholecystectomy provides a guide for subsequent endoscopic biliary access and stone removal, minimzing the risks of a repeated endoscopic failure or the need for percutaneous or EUS-guided rendezvous cannulation.

Mo1309 Intraoperative ERCP With Guidewire Assisted Rendezvous Cannulation; A Laparo-Endoscopic Way to Avoid Post ERCP Pancreatitis

Mo1309 Intraoperative ERCP With Guidewire Assisted Rendezvous Cannulation; A Laparo-Endoscopic Way to Avoid Post ERCP Pancreatitis Fredrik Swahn*, Sara Regner, Lars Enochsson, Lars R. Lundell, Henrik Thorlacius, Urban Arnelo Gastrocentrum Surgery, CLINTEC, Stockholm, Sweden; Department of Surgery, Clinical Sciences, Malmo Skane University Hospital, Malmo, Sweden Background: Laparoscopic cholecystectomy (LC) can be combined with endoscopic retrograde cholangiopancreatography (ERCP) in conjunction with transcystic guidewire assisted rendezvous (RV) cannulation in the management of common bile duct stones (CBDS). The aim of this study was to examine whether this approach is associated with a lower pancreatic proenzyme leakage rate than conventional (CV) ERCP cannulation technique. Methods: Patients (n 122) with symptomatic gallstone disease, without ongoing pancreatitis, cholangitis, cholecystitis or previous sphincterotomy were prospectively enrolled in this case control designed study. Forty of these patients had an LC where the per-operative cholangiogram suggested CBDS including a laparo-endoscopic (LE) RV. Another 41 patients with retained CBDS cholecystolithiasis underwent CV ERCP. Patients (n 41) submitted to LC and cholangiographie with negative findings served as a control group. Post-procedural pancreas amylase, trypsinogen-2 and procarboxy-peptidase B (proCAPB) blood concentrations were analyzed in all patients as well as perand post-procedural complications and CBDS clearance rates. Results: Post ERCP pancreatitis (PEP) occurred in 3 of the 41 (7%) patients submitted to CV ERCP as compared to none in the RV ERCP group (p 0.11, n.s.). Laboratory values suggestive of acute pancreatic injury such as pancreas amylase 4 hours after ERCP were 2.0 4.2 [SD] cat/L in the CV ERCP group, 0.5 0.33 cat/L in the RV ERCP group (P-value 0.0015). At 8 hours the corresponding values were 3.5 9.0 cat/l and 0.6 0.4 cat/l, respectively (p 0.03). ProCAPB after 4 hours was 90.7 237.7 nmol/L compared to 7.2 8.0 nmol/L after RV ERCP (p 0.0001) and after another 4 hours of observation corresponding values were 111.7 287.3 nmol/L and 7.9 7.6 nmol/L (p 0.0001) respectively (Fig.1). Trypsinogen-2 levels at 24 hours after procedure were 317.8 547.1 g/L in the CV ERCP group, 145.6 67.2 g/L (p 0.03) after RV ERCP and 134.0 80.3 g/L among the controls. No major per-or post procedural complications were observed in either groups. Post procedural concentrations of pancreas amylase (p 0.003) and proCAPB (p 0.002) were significantly correlated with pancreatic duct cannulation and opacification. Albeit that the final outcome in both study groups eventually reach complete stone clearance, there was a significant (p 0.01) advantage for the RVgroup (n 38/40, 95%) during the index procedure, compared with the CV-group (29/41, 71%). Conclusion: One-stage LE ERCP in conjunction with guidewire assisted RV cannulation minimizes pancreatic enzyme leakage compared with CV cannulation technique. These results suggests that RV technique is an important LE therapeutic method that can be employed to prevent PEP and thereby should be the preferred technique for transpapillary CBDS extraction in conjunction with LC.

Double-guidewire-assisted Cannulation in ERCP

Even in experienced hands, a common problem at endoscopic retrograde cholangiopancreatography (ERCP) is difficulty in reaching a selective cannulation of the common bile duct or pancreatic duct. The success rate of biliary cannulation has improved markedly in many centers after the adoption of double-guidewire-assisted cannulation technique in cases in which the guidewire repeatedly passes into the pancreatic duct although the common bile duct is intended. Here, we describe 2 novel applications of the double-guidewire technique for difficult cannulation in ERCP. In particular, we emphasize that in addition to difficult biliary cannulation, double-guidewire technique may prove useful in difficult pancreatic cannulation. The double-guidewire technique is feasible also in cases in which the guidewire repeatedly passes into the cystic duct instead of the intended common hepatic duct and intrahepatic radicals. ERCP endoscopists should be aware of all modifications of double-guidewire technique to further increase the success rates of selective cannulations in ERCP.

Mo1488 Long Term Follow-Up After Needle Knife Sphincterotomy for Biliary Access: A Blinded Comparative Clinical, Sonographic and Endoscopic Study

Needle Knife Sphincterotomy (NKS) or precut is an important salvage technique in difficult biliary cannulation during Endoscopic Retrograde Cholangiopancreatography(ERCP). Recent data suggests that NKS may be safer than repeated standard attempts at biliary cannulation, however data on long term outcomes after NKS is absent. Sequential NKS patients were analysed from a clinical trials ERCP database consisting of 3 successive, prospective naïve papilla ERCP cannulation trials of 1232 patients. Two control groups of 145 patients each without NKS: ‘Early Cannulation’(1-4 attempts) and ‘Late Cannulation’(>4 attempts) were also randomly selected and matched for age, follow-up time and indications for ERCP. All patients had biliary sphincterotomy at initial ERCP. Patients were mailed a validated screening biliary symptom assessment questionnaire, followed by a telephone interview in non-respondents. Those with suspected biliary symptoms were assessed clinically and with ultrasound and liver function tests by a Gastroenterologist blinded to all previous ERCP data. Patients with true biliary symptoms or abnormal investigations were evaluated by ERCP with balloon impaction cholangiography and 10mm balloon pull through. Results were analyzed using the Fisher Exact or Pearson's Chi Square tests as appropriate. After allowing for those patients that were deceased or lost to follow-up, a total of 183 patients were available(112 females, mean age 60 years; range 21-91). Table 1 summarizes the results.Of those patients with true biliary symptoms, only 1 patient had an abnormal ultrasound. Liver function tests were essentially normal in all. Standardised ERCP was performed in the 7 patients with true biliary symptoms and was found to be normal in all.Table 1CriterionNKS n=124Early Cannulation n=145Late Cannulation n=145p-valueNumber of patients lost to follow-up455954Number of deceased patients281827Number of evaluable patients516864Mean follow-up time in years (SD)5.1 (1.4)5.4 (1.4)5.6 (1.5)NSSymptomatic on screening questionnaire N(%)12(23.5)9(13.2)7(10.9)NSPrevalence of true biliary symptoms-N (%)1(2.0)4(5.9)2(3.1)NS Open table in a new tab In long term follow-up, NKS is not associated with an increased incidence of biliary symptoms when compared to Early or Late Cannulation controls. In all groups symptomatic biliary stenosis is uncommon. NKS does not lead to late biliary complications.

A new guidewire cannulation technique in ERCP: successful deep biliary access with triple-lumen sphincterotome and guidewire controlled by the endoscopist

Current studies have addressed ways to improve the success of selective biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP). The objective of this study was to assess the efficacy of deep bile duct access using a short-wire system with sphincterotome and guidewire controlled only by the endoscopist. This was a prospective study of 70 patients with biliary diseases subjected to ERCP. Biliary cannulation was performed by the endoscopist without direct cooperation of the assistant in two centers with different experience in ERCP. The RX Biliary System™ was used in all patients. Efficacy (success rate and time to cannulation) of deep bile duct access and procedure-related complications were determined. Overall guidewire cannulation was successful in 65 of 70 patients (92.9%). Nonintentional pancreatic duct cannulation with the guidewire was performed in 22 patients (31.4%). Additional techniques were needed in 18 patients (25.7%): guidewire into the pancreatic duct in 11 patients (15.7%); contrast-medium was used in 13 patients (18.6%); and precut was performed in 3 patients (4.3%). Attempts at papilla cannulation numbered<10 in 48 patients (68.6%), and time to biliary cannulation was <10 min in 42 patients (60%). Minor complications occurred in five patients (7.1%). There were no significant differences between patients in both centers. The short-wire system allows the endoscopist to have access to the bile duct with a high success rate--early and safely--without the direct participation of the assistant.

Myocardial ischemia during endoscopic retrograde cholangiopancreatography: An overlooked issue with significant clinical impact

The occurrence of peri-procedural myocardial ischemia with endoscopic retrograde cholangiopancreatography (ERCP) has been documented, but its significance remains controversial. This study aimed to investigate the incidence and risk factors of myocardial ischemia during ERCP procedures and to analyze the potential association between myocardial ischemia and post-ERCP complications. Ambulatory 24-h ST-segment monitoring from 30 min prior to 24 h after ERCP was obtained on 71 patients from September 2006 to August 2007. Changes in vital signs during ERCP, post-ERCP complications, and their outcomes were recorded and analyzed. Cardiac ischemia occurred in 13 patients (18.3%) during ERCP and one patient developed myocardial infarction. More patients in the ischemic group (38.5%) than in the non-ischemic group (5.2%) had ST-T changes in pre-ERCP resting electrocardiography (P < 0.01). Hypotension during ERCP was found only in the ischemic group (15.4% vs 0%; P = 0.03). Patients with cardiac ischemia during ERCP had a significantly higher rate of elevated serum amylase and lipase levels (53.8% vs 15.5%; P < 0.01) and post-ERCP pancreatitis (30.8% vs 6.9%; P = 0.03). Multivariable logistic regression analysis revealed that cardiac ischemia during ERCP (OR: 5.21, P = 0.050) and pancreatic duct cannulation (OR: 5.7, P = 0.036) were independent predictors for post-ERCP pancreatitis. ST-T changes on resting electrocardiography and intra-procedural hypotension are risk factors of myocardial ischemia during ERCP. Post-ERCP hyperamylasemia, hyperlipasemia, and pancreatitis were associated with myocardial ischemia during ERCP.

Difficult Biliary Cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure routinely performed by endoscopists. ERCP cannulation requires the insertion of a subcentimeter catheter through a tiny orifice at a distance of almost a meter from the operator. Only after successful cannulation of the bile duct can the real "business" of ERCP be performed (eg, sphincterotomy, stone extraction, stent placement). Selective bile duct cannulation is all the more exacting due to the occasional anatomic challenge (eg, postsurgical anatomy, duodenal stricture) or wayward catheter. Serious morbid complications can and do occur, even in the hands of the most gifted and facile endoscopists. Although there are some "tricks" to facilitate successful cannulation of the bile duct, experience "trumps" all tricks. Of greatest importance when faced with a difficult cannulation is the recognition of one's personal limitations.

Advances in endoscopic retrograde cholangiopancreatography cannulation

Endoscopic retrograde cholangiopancreatography is an important tool in the diagnosis and treatment of pancreatobiliary diseases. A critical step in this procedure is deep cannulation of the bile duct as failure of cannulation generally results in an aborted procedure and failed intervention. Expert endoscopists usually achieve a high rate of successful cannulation while those less experienced typically have a much lower rate and a greater incidence of complications. Prolonged attempts at cannulation can result in significant morbidity to patients, anxiety for endoscopists, unnecessary radiation exposure and inefficient patient care. Here we review the most common endoscopic techniques used to achieve selective biliary cannulation. Pharmacologic aids to cannulation are also discussed briefly in this review.

Predictors of Difficult or Failed Endoscopic Retrograde Cholangiopancreatography Cannulation in Clinical Practice

Purpose: Difficult/failed endoscopic retrograde cholangiopancreatography (ERCP) cannulation rates range from 5%-20% and is an independent risk factor for post ERCP complications. The aim of our study was to determine clinical, biochemical and patient demographic factors that predict difficult or failed ERCP cannulation. Methods: Retrospective chart review of all patients who underwent ERCP procedure between January 2006 and October 2008 at two community medical centers was performed and appropriate demographic, clinical and biochemical factors were extracted for analysis. All patients who underwent ERCP for the first time were included in the study and all patients with a previous history of ERCP procedure were excluded. Difficult ERCP cannulation was defined when there was difficulty/failure to cannulate the ampulla or if the total duration of the procedure exceeded 45 minutes. Univariate and multivariate logistic regression analysis was performed to identify the predictors of difficult/failed cannulation. Results: 220 patients underwent ERCP of which 146 patients (Table 1) who met the inclusion criteria were included in the study. 25% (n=36) of patients had difficult/failed ERCP cannulation. Multivariate analysis revealed previous gastrointestinal (GI) surgery (OR 2.59; 95% CI 1.21-5.57; p=0.01), age (OR 1.03 95% CI 1.01-1.06 P value 0.0017) and history of smoking (OR 3.16; 95% CI 1.43 - 6.97; p=0.004) to be significantly associated with difficult or unsuccessful cannulation.Table 1: Baseline characteristics of the patientsConclusion: Elderly patients, smokers and patients with prior GI surgery are at a higher risk for difficult or failed ERCP cannulation. These factors needed to be considered when individualizing the choice of technique prior to ERCP.

Endoscopic precut sphincterotomy for cannulation of inaccessible common bile duct： transpancreatic septum precut versus needle-knife

Objective To evaluate the technique of transpancreatic septum precut for cannulation of inaccessible common bile duct in endoscopic retrograde cholangiopancreatography （ERCP）. Methods Data of 109 patients with difficult biliary cannulation in ERCP, of whom 56 underwent transpancreatic septum precut and 53 had needle-knife sphincterotomy from January 2006 to July 2008, were analyzed retrospectively, and the success rate of cannulation and the occurrence of complications were compared between the two methods. Results Of 109 patients accepted precut papillotomy, common bile duct cannulation was successfully achieved in 97. The success rates of transpancreatic septum precut group and needle-knife sphincterotomy group were 96. 4% （54/56） and 81.1% （43/53） respectively, which was significantly different （ P 〈 0.05 ）. Complications occurred in 11 cases, including bleeding（ n = 4）, acute pancreatitis （ n = 5 ）, cholangitis（n = 2 ）. The tolal frequency of complications of the transpancreatic septum pre-cut papillotomy group was lower than that of needle-knife sphincterotomy group（3.6% vs. 17. 0% , P 〈 0. 05 ）. Conclusion In patients with inaccessible bile ducts, transpancreatic septum precut is a safe and effective procedure in cannulation, exhibiting a higher success rate and lower occurrence of complication when compared with needleknife sphincterotomy. Key words: Cholangiopancreatography, endoscopic retrograde ; Common bile duct ; Precut ; Septnm ; Postoperative complications

Comparison of early pre-cuttingvsstandard technique for biliary cannulation in endoscopic retrograde cholangiopancreatography: A personal experience

To compare the results and complications of early pre-cutting technique with standard technique. From January 2003 to December 2004, a total of 416 consecutive therapeutic biliary ERCP procedures were performed by one endoscopist (T.A.). Data were retrospectively collected according to procedure indication and results. Of these, 293 procedures (70.4%) were done with standard technique (group A) and 123 procedures (29.6%) with early pre-cutting technique in case of difficult cannulation (group B). The results and complications of ERCP were compared. Success rate of first attempt cannulation was 98.0% in group A and 87.8% in group B. The overall incidence of post-ERCP pancreatitis, hemorrhage, perforation and cholangitis was 0%, 0.2%, 0.5% and 0.5%, respectively. Morbidity rate was not significantly different. No procedure-related mortality was occurred. For an experienced hand, the early pre-cutting technique for biliary cannulation is safe and effective as standard technique.

ERCP after a liquid fatty meal: comment

I was very interested by the study by Barrie and Klein recently published in Endoscopy [1], as it describes a very simple and apparently innocuous method of improving cannulation in endoscopic retrograde cholangiopancreatography (ERCP). I would, however, like to point out that the authors did not mention the depth of sedation (light, moderate, or anesthesia), or the drugs used to sedate the patients in the study (some drugs used in sedation for ERCP have a potential to cause contraction of the sphincter of Oddi), or whether the sedation was administered by an anesthesiologist. I would also like to point out that the clear liquid meals ingested 2 h before elective procedures requiring general anesthesia, as recommended by the American Society of Anesthesiology, are intended for children, and that the liquid meal used in the study was intentionally a fatty liquid meal and not a clear liquid one.

Needle-knife assisted ERCP

During endoscopic retrograde cholangiopancreatography (ERCP), incising through the wall of the major papilla with an electrocautery needle-knife is a method for achieving access into the bile duct. This procedure, often referred to as a "precut," may be used when cannulation attempts via the orifice of the papilla are unsuccessful. Potential complications include hemorrhage, duodenal perforation, and acute pancreatitis. The 172 patients who underwent an attempt of a needle-knife assisted ERCP during the years 1997-2003 at our institution were retrospectively evaluated. A selective bile duct cannulation was achieved after needle-knife incision in 148 out of 172 patients (86%) at the primary session. In 10 additional patients (6%), a repeated procedure proved successful for cannulation. In the remaining 14 patients (8%), the biliary cannulation failed and was not attempted again. Complications after needle-knife assisted ERCP occurred as follows: three patients (2%) presented with late bleeding after the ERCP and three patients (2%) developed acute pancreatitis. None of the patients required operative treatment for complications. There was no mortality. The use of the needle-knife markedly improves the success rate of selective biliary cannulation in ERCP without increasing the rate of complications.

ERCP in post-Billroth II gastrectomy patients: emphasis on technique

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) in post-Billroth II (BII) gastrectomy is more difficult due to anatomical changes. The difficulties include entrance to the afferent loop and selective cannulation. Our aim here is to report the success rate and special manipulations and techniques of this procedure. Methods: A retrospective review of 56 ERCP procedures in post-BII gastrectomy patients was performed. There were 43 male and 13 female patients with a mean age of 63 yr (range, 32–78 yr). All cases were tried with forward-viewing endoscope first. Of the failed cases, 10 were retried by side-view duodenoscope. The entrance to the afferent loop was attempted by starting from the upper opening at the anastomosis site and, if this failed, then using the lower opening; presence of bile; and air-contrasted afferent loop under fluoroscopy. If failure of afferent loop entrance resulted, hand compression over the mid-abdomen, or polypectomy snare in the working channel of the endoscope, was tried. For failure of common bile duct cannulation with straight catheters, techniques of pushing the catheter against the duodenal wall and bending the tip of the endoscope or guidewire were used. Results: The success rate of afferent loop entrance was 76.7% (43 of 56 cases). The afferent loop was identified in the upper orifice of the anastomosis in 93% (40 of 43) of the cases. Eight cases of afferent loop entrance could be facilitated by hand compression, and three by polypectomy snare in the working channel of the endoscope. The success rate of ERCP cannulation in those successful afferent loop intubation cases was 81.3% (35/43 cases). Most of the selective common bile duct (CBD) cannulation was achieved by straight (new) catheter and an additional six cases were successful using the techniques mentioned. No serious complications were encountered, except three cases of submucosal hemorrhage. Conclusion: The overall success rate of BII ERCP was 62.5% (35 of 56 cases). The special manipulations mentioned in BII ERCP can be helpful in certain cases.

ERCP in post-Billroth II gastrectomy patients: emphasis on technique.

Endoscopic retrograde cholangiopancreatography (ERCP) in post-Billroth II (BII) gastrectomy is more difficult due to anatomical changes. The difficulties include entrance to the afferent loop and selective cannulation. Our aim here is to report the success rate and special manipulations and techniques of this procedure. A retrospective review of 56 ERCP procedures in post-BII gastrectomy patients was performed. There were 43 male and 13 female patients with a mean age of 63 yr (range, 32-78 yr). All cases were tried with forward-viewing endoscope first. Of the failed cases, 10 were retried by side-view duodenoscope. The entrance to the afferent loop was attempted by starting from the upper opening at the anastomosis site and, if this failed, then using the lower opening; presence of bile; and air-contrasted afferent loop under fluoroscopy. If failure of afferent loop entrance resulted, hand compression over the mid-abdomen, or polypectomy snare in the working channel of the endoscope, was tried. For failure of common bile duct cannulation with straight catheters, techniques of pushing the catheter against the duodenal wall and bending the tip of the endoscope or guidewire were used. The success rate of afferent loop entrance was 76.7% (43 of 56 cases). The afferent loop was identified in the upper orifice of the anastomosis in 93% (40 of 43) of the cases. Eight cases of afferent loop entrance could be facilitated by hand compression, and three by polypectomy snare in the working channel of the endoscope. The success rate of ERCP cannulation in those successful afferent loop intubation cases was 81.3% (35/43 cases). Most of the selective common bile duct (CBD) cannulation was achieved by straight (new) catheter and an additional six cases were successful using the techniques mentioned. No serious complications were encountered, except three cases of submucosal hemorrhage. The overall success rate of BII ERCP was 62.5% (35 of 56 cases). The special manipulations mentioned in BII ERCP can be helpful in certain cases.