Fig. 1The technique of wire-guided cannulation of the bile duct. (A) In patients with Billroth II gastrectomy, the ampulla was seen in a reversed position in the gastroscopic view. (B) An en face view of the papilla obtained by controlling the endoscope; a hydrophilic guidewire 0.035-inch in a diameter was preloaded into a triple lumen catheter. After minimal insertion (2 to 3 mm) of the catheter in the ampulla, the guidewire was carefully advanced through the common bile duct (CBD) under fluoroscopy until it was seen to enter the bile duct. Pushing the catheter against the duodenal wall at the 9 to 10 o'clock position or bending the tip of the endoscope (with the protruding tip of the catheter in the orifice of the papilla and upwards bending of the tip of the endoscope) led the tip of the catheter to the correct access to the CBD, i.e., at the 4 to 5 o'clock position. (C) After the catheter was removed, the guidewire was left in the lumen of CBD. (D) Endoscopic sphincterotomy by using a Soehendra Billroth II sphincterotome was performed along the guidewire directed at the 5 o'clock.
Fig. 2Endoscopic views of common bile duct (CBD) stone removal by using only endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation (EPBD) in a patient with Billroth II gastrectomy. (A, B) After only EST of the major papilla was performed, a CBD stone was removed with a stone basket catheter. (C, D) After EPBD followed by EST, relatively large stones were easily extracted out of the bile duct with a balloon catheter.
Fig. 3Needle knife fistulotomy in two patients with Billroth II gastrectomy. (A, B) After selective biliary cannulation failed, an en face view of the papilla was obtained by controlling the endoscope. After a small and deep incision was performed on the reversed roof of the ampulla by using needle knife, access to the common bile duct was obtained.
Fig. 4Flow chart of the treatment results of 46 patients with Billroth II gastrectomy. CBD, common bile duct; IHD, intrahepatic bile duct; PTCS, percutaneous transhepatic choledochoscopy.
Table 1Patient Characteristics and Final Diagnoses after ERCP in Patients Who Had Undergone Billroth II Gastrectomy
Table 2Success and Failure Rates of Endoscopic Retrograde Cholangiopancreatography Using a Forward-Viewing Endoscope in 42 Patients with Billroth II Gastrectomy
Table 3The Results of Endoscopic Stone Removal in 29 Patients with Billroth II Gastrectomy