A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy

doi:10.1067/mge.2001.110454

Gastrointestinal Endoscopy

Volume 53, Issue 1, January 2001, Pages 19-26

Presented in part at the Annual Meeting of the American Society for Gastrointestinal Endoscopy, Orlando, Fla., May 1999 (Gastrointest Endosc 1999;49:4[part II]:AB656).

https://doi.org/10.1067/mge.2001.110454 Get rights and content

Abstract

Background: A prior Billroth II gastrectomy renders endoscopic sphincterotomy (EST) more difficult in patients with bile duct stones. Endoscopic balloon dilation (EBD) is a relatively easy procedure that potentially reduces the risk of bleeding and perforation. Methods: Thirty-four patients with bile duct stones and a previous Billroth II gastrectomy were randomized to EST or EBD. Complications were graded in a blinded fashion. Results were compared with those for a group of 180 patients with normal anatomy from a previously reported randomized trial of EBD versus EST. Results: All stones were removed in 1 endoscopic retrograde cholangiopancreatography in 14 of 16 patients who underwent EBD versus 14 of 18 who had EST (p = 1.00). Mechanical lithotripsy was used in 3 EBD procedures versus 4 EST procedures (p = 1.00). Early complications occurred in 3 patients who had EBD versus 7 who underwent EST (p = 0.27). Three patients had bleeding after EST; 1 patient had mild pancreatitis after EBD. The median time required for stone removal was 30 minutes in both groups. Compared with patients with a normal anatomy, patients with a previous Billroth II gastrectomy had a significantly increased risk of bleeding after EST (17% vs. 2%, relative risk = 7.25, p < 0.05). Conclusions: A prior Billroth II gastrectomy renders EST more difficult and increases the risk of a complication. EBD in these patients is easy to perform and is not associated with an increased need for mechanical lithotripsy or a longer procedure time. The risk of bleeding is virtually absent after EBD and the risk of pancreatitis after EBD seems not significantly increased in these patients. (Gastrointest Endosc 2001;53:19-26.)

Section snippets

Selection of patients and randomization

Patients fulfilled the following criteria for entry in the study: (1) referred for ERCP because of symptoms of bile duct stones, (2) age older than 18 years, (3) informed consent obtained before ERCP, (4) bile duct stones visualized at ERCP, and (5) deep cannulation of the bile duct achieved without precut sphincterotomy. Patients were excluded from the study if there were signs of acute cholangitis (temperature greater 38.5°C within 12 hours before ERCP), acute pancreatitis (severe epigastric

Selection of patients and randomization

Between January 1, 1993 and December 31, 1995, 67 patients with prior Billroth II gastrectomy underwent ERCP because of a suspicion of bile duct stones; 34 patients were enrolled in the study. Reasons for exclusion were papilla not reached because of a long afferent loop (n = 7), Braun enteroenterostomy (n = 6), or Roux-en-Y anastomosis (n = 3); precut sphincterotomy necessary for access to the common bile duct (n = 6); cholangitis (n = 4) or pancreatitis (n = 4) at the time of ERCP,

Discussion

Relatively few studies have been published on endoscopic stone removal in patients with a prior Billroth II gastrectomy. It is difficult to draw conclusions about the success rate and complication rate of EST in these patients. The reason for this is 4-fold. First, all studies are retrospective analyses that often cover a long period of time. Second, most of them have small sample sizes that consist of a mixture of different indications and diseases (e.g., malignancy and stone disease). Third,

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Long-term outcomes of endoscopic papillary large-balloon dilation (12–15 mm) with or without limited sphincterotomy for removal of bile duct stones
2023, Hepatobiliary and Pancreatic Diseases International
Limited endoscopic sphincterotomy with large balloon dilation (ES-LBD) and endoscopic papillary large-balloon dilation (EPLBD) have been proven safe and effective for removal of bile duct stones. However, the long-term outcomes are not clear. The aim of this study was to assess the long-term outcomes of EPLBD (12–15 mm) with or without limited sphincterotomy for removal of common bile duct (CBD) stones.
Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed. Complete stone clearance, endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events, and late biliary complications during long-term follow-up were analyzed.
Basic patient characteristics were not significantly different between the groups that underwent EPLBD (n = 168) and ES-LBD (n = 57). EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal (99.4% vs. 100%, P = 1.00) and ERCP-related adverse events (7.7% vs. 5.3%, P = 0.77). The mean duration of the follow-up were 113.6 months and 106.7 months for patients with EPLBD and ES-LBD, respectively (P = 0.13). There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence [20 (11.9%) vs. 9 (15.8%); P = 0.49]. Multivariate analysis showed that a diameter of CBD ≥ 15 mm (OR = 3.001; 95% CI: 1.357–6.640; P = 0.007) was an independent risk factor for stone recurrence.
The application of a large balloon (12–15 mm) via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones. Endoscopic sphincterotomy prior to EPLBD may be unnecessary. A diameter of CBD ≥ 15 mm is a risk factor of stone recurrence.
Revision of the common bile duct in a combined PTCD/ERC approach – A case report
2021, International Journal of Surgery Case Reports
The endoscopic retrograde cholangiography (ERC) represents the standard treatment for choledocholithiasis. However, ERC in patients with previous gastrectomy and anastomosis is difficult due to altered access.
In our case, we report on a patient with previous gastrectomy and Y-Roux-anastomosis suffering from choledocholithiasis. Operative revision with simultaneous cholecystectomy failed. In a combined procedure of percutaneous transhepatic cholangiodrainage (PTCD) and endoscopic cholangiography the stone removal of the common bile duct was finally successful.
There are some approaches for treatment of choledocholithiasis in pre-operated patients. However, prospective multi-center studies for complication and success rates are not available due to the rarity of such cases.
Interdisciplinary procedures seem to be the safest and most promising way to succeed in the treatment of choledocholithiasis in challenging cases.
Postsurgical Endoscopic Anatomy
2019, Clinical Gastrointestinal Endoscopy
Patients who have undergone surgical procedures that altered the upper gastrointestinal (GI) anatomy are often referred for endoscopic evaluation. It is essential for gastroenterologists to understand the postoperative anatomical alterations to select the appropriate endoscope and accessories and obtain meaningful and accurate diagnostic information. This chapter discusses the most common surgical procedures involving the upper GI tract. Technical details and common variations are described for each surgical procedure. The endoscopic correlates to anatomical alterations are described. Available surgical reports should always be reviewed before the endoscopic examination.
Self-expandable metal stents for choledocholithiasis in Billroth II gastrectomy patients
2018, Hepatobiliary and Pancreatic Diseases International
Citation Excerpt :
Conventionally, EST and EPBD are performed for ampullary intervention in patients with a prior Billroth II gastrectomy. Compared with normal anatomy, EST in patients with a previous Billroth II gastrectomy resulted in lower rate of stone clearance, high rates of early complications, and increased rate of bleeding [19]. Recent studies reported that EPBD was superior to EST in reducing bleeding rate of patients with altered anatomy [20].
Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents (FCSEMSs) for the management of common bile duct (CBD) stones in a subset of patients with a history of Billroth II gastrectomy.
This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed.
A group of 15 patients (10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation (6), small or flat papilla with unclear margin (5), current use of double antiplatelet agents or an anticoagulant (2), unwanted instrumentation of the cystic duct (1), and insecure position of the scope (1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications.
Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.
Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth II gastrectomy patients
2018, Hepatobiliary and Pancreatic Diseases International
Endoscopic papillary balloon dilation (EPBD) for common bile duct (CBD) stones removal in Billroth II gastrectomy patients is feasible. However, the long-term outcomes of this technique are not clear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth II gastrectomy patients.
The records of patients with previous Billroth II gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography (ERCP) between July 1, 2008 and September 1, 2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events, and stone recurrence were analyzed.
A total of 83 patients with previous Billroth II gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth II gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients (85.7%). ERCP-related adverse events was in 3 ERCP procedures (5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients (12.2%) had stone recurrence after a median period of 22.5 months (range 6–71 months) from the end of stone removal treatment. Female [odds ratio (OR) = 11.352; 95% confidence interval (95% CI): 1.040–123.912; P = 0.046] and previous mechanical lithotripsy (OR = 13.423; 95% CI: 1.070–168.434; P = 0.044) were significantly associated with stone recurrence.
At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth II gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.
Choledocholithiasis
2018, ERCP, Third Edition
Endoscopic retrograde cholangiography (ERCP) is a valuable multifaceted diagnostic and therapeutic tool in gastroenterology. In addition to astute hand-eye coordination and technical skills, ERCP requires an appreciation of preprocedural preparation and a depth of knowledge and thoughtfulness to respond to unexpected intraprocedural findings and challenges. This chapter focuses on the evaluation and management of choledocholithiasis, one of the most common indications for ERCP.

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^☆: Reprint requests: J. J. G. H. M. Bergman, MD, Dept. of Gastroenterology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.

^☆☆: Gastrointest Endosc 2001;53:19-26

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Original ArticlesA randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy☆,☆☆

Abstract

Section snippets

Selection of patients and randomization

Selection of patients and randomization

Discussion

Gastrointest Endosc

Lancet

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Needle-knife sphincterotomy guided by a biliary endoprosthesis in Billroth II gastrectomy patients

Endoscopy

Endoscopic sphincterotomy using an S-shaped sphincterotome in patients with a Billroth II or Roux-en-Y gastrojejunostomy

Endoscopy

Endoscopic papillary dilation: an alternative to papillotomy?

Deutsch Med Wochenschr

Endoscopic papillary balloon dilation for the management of common bile duct stones: experience of 226 cases

Endoscopy

Endoscopic balloon sphincteroplasty (papillary dilation) for bile duct stones: efficacy, safety, and follow-up in 100 patients

Gastrointest Endosc

What is the current status of endoscopic balloon dilation for stone removal?

Endoscopy

Original Articles
A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy☆,☆☆