Endoscopic Papillary Large Balloon Dilation Combined with Guidewire-Assisted Precut Papillotomy for the Treatment of Choledocholithiasis in Patients with Billroth II Gastrectomy

Abstract

Background/AimsEndoscopic extraction of bile duct stones is difficult and often complicated in patients with a Billroth II gastrectomy. We evaluated a simpler technique to achieve an adequate ampullary opening for the removal of choledocholithiasis using endoscopic papillary large balloon dilation (EPLBD) combined with a guidewire-assisted needle-knife papillotomy.MethodsSixteen patients who had a Billroth II gastrectomy were included in this study. Following placement of the guidewire in the bile duct, a precut incision was made over the guidewire with a needle knife sphincterotome inserted alongside the guidewire. Balloon dilation of the ampullary orifice was gradually performed.ResultsNeedle knife papillotomy over the guidewire with subsequent EPLBD was successful in all patients. Complete stone removal was achieved in 15 (93.7%) patients in 1 session. However, 1 (6.3%) patient required mechanical lithotripsy with an additional procedure for complete ductal clearance, and there was 1 case of minor bleeding following the EPLBD. There were no cases of pancreatitis or perforation.ConclusionsEPLBD followed by guidewire-assisted needle-knife papillotomy appears to be a useful method with few technical difficulties and a low risk of complications for the removal of bile duct stones in patients with prior Billroth II gastrectomy.

Endoscopic papillary large balloon dilation for the retrieval of bile duct stones after prior Billroth II gastrectomy

“…[45678] In the present study, the overall CBD stone removal and complete stone removal rates for first endoscopic session were 96.7% and 90.0%, respectively, which concur with previous studies. [45678] Mechanical lithotripsy is an annoying but essential procedure for the removal of large bile duct stones. The wider ampullary opening made during EPLBD can aid the removal of difficult stones and lower the requirement of mechanical lithotripsy.…”

“…[5] However, several studies have reported substantially lower rates of post-ERCP pancreatitis after EPLBD in patients with prior B-II gastrectomy (0-5%). [4578] In the present study, only two cases (6.7%) of pancreatitis were observed and both were mild and self-limiting.…”

“…[5678] As compared with conventional ES, EPLBD is technically easier in patients with B-II gastrectomy. Nevertheless, the potential risks of perforation are of particular concern because its mortality is quite high compared with patients with normal anatomy.…”

Updated guideline on the management of common bile duct stones (CBDS)

“…As discussed in previously, there remain concerns about the risk of pancreatitis in patients undergoing EPBD without prior sphincterotomy. An approach that combines limited biliary sphincterotomy with a needle knife over a straight plastic biliary stent or guidewire, followed by EPBD and conventional stone extraction, has been reported 186. It is becoming the method preferred by experts, and potentially combines ease of use, safety and efficacy.…”

Bile duct stone formation around a nylon suture after gastrectomy: A case report

“…It is relatively difficult to carry out endoscopic treatment with Roux-en-Y anastomosis and the Billroth II method because of the surgically altered anatomy [8]. The success rate of ERCP using the Billroth II method is lower in patients with choledocholithiasis (63–93%) than in patients with an intact stomach (87–97%) [9].…”