Ampullary intervention for bile duct stones in patients with surgically altered anatomy

Abstract

Transpapillary endoscopic treatment is a standard technique for the treatment of bile duct stones. This technique includes biliary cannulation, ampullary interventions such as endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilation (EPBD), and stone removal. In patients with Roux‐en‐Y anastomosis, the transpapillary approach using an ordinary scope has been challenging. A recently developed single‐/double‐balloon enteroscope enables therapeutic endoscopic retrograde cholangiopancreatography to be carried out in such cases. EST using a balloon enteroscope is often difficult to carry out as a result of restriction of scope maneuverability or inadequate direction of the accessory. Although EPBD is easy to carry out for any anatomy, large or multiple stones are difficult to remove by EPBD only because of insufficient opening of Vater's papilla. Endoscopic papillary large‐balloon dilation following EST is reported to be useful for the treatment of large and/or multiple stones. This technique is also useful for the treatment of bile duct stones in patients with Roux‐en‐Y anastomosis.

Endoscopic management of bile duct stones in patients with surgically altered anatomy

“…Once the endoscope successfully reaches the ampulla, biliary cannulation followed by ampullary intervention, either cut, dilate or both, is necessary to remove bile duct stones. Biliary cannulation and ampullary interventions in patients with surgically altered anatomy were previously reviewed in detail.…”

“…O NCE THE ENDOSCOPE successfully reaches the ampulla, biliary cannulation followed by ampullary intervention, either cut, dilate or both, is necessary to remove bile duct stones. Biliary cannulation 5 and ampullary interventions 34 in patients with surgically altered anatomy were previously reviewed in detail. Biliary cannulation can be technically difficult because the direction of biliary cannulation in surgically altered anatomy is opposite to that of regular ERCP.…”

Endoscopic Retrograde Cholangiopancreatography in Post Gastrectomy Patients

“…EST is one of the standard techniques for treating bile duct stones in post-gastrectomy patients. EST is usually performed with a push-type sphincterotome or a wire-guided needle knife in post-gastrectomy patients because of inverted anatomy of the ampulla of Vater [24]. After placing a biliary stent, making an incision with a needle knife over the stent is also a useful technique [25].…”

Comparison between double‐guidewire technique and transpancreatic sphincterotomy technique for difficult biliary cannulation

“…Furthermore, more advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices . For surgically altered gastrointestinal anatomy, some special skills should be considered . Enterography route, which crosses the greater curvature of the stomach and the ‘lower entrance’ at the site of the gastrojejunal anastomosis, along the efferent loop, and goes through the ‘middle entrance’ at the site of the Braun anastomosis to reach Vater's papilla, is optimal for patients with Billroth II gastroenterostomy and Braun anastomosis .…”

“…4 For surgically altered gastrointestinal anatomy, some special skills should be considered. 5,6 Enterography route, which crosses the greater curvature of the stomach and the 'lower entrance' at the site of the gastrojejunal anastomosis, along the efferent loop, and goes through the 'middle entrance' at the site of the Braun anastomosis to reach Vater's papilla, is optimal for patients with Billroth II gastroenterostomy and Braun anastomosis. 7,8 For patients with cholecystolithiasis and choledocholithiasis, the rendezvous technique is appropriate, accompanied by laparoscopic cholecystectomy.…”