ERCP for patients who have undergone Billroth II gastroenterostomy and Braun anastomosis

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is efficacious in patients who have undergone Billroth II gastroenterostomies, but the success rate decreases in patients who also have experienced Braun anastomoses. There are currently no reports describing the preferred enterography route for cannulation in these patients. We first review the patient's previous surgery records, which most often indicate that the efferent loop is at the greater curvature of the stomach. We recommend extending the duodenoscope along the greater curvature of the stomach and then advancing it through the "lower entrance" at the site of the gastrojejunal anastomosis, along the efferent loop, and through the "middle entrance" at the site of the Braun anastomosis to reach the papilla of Vater. Ten patients who had each undergone Billroth II gastroenterostomy and Braun anastomosis between January 2009 and December 2011 were included in our study. The overall success rate of enterography was 90% for the patients who had undergone Billroth II gastroenterostomy and Braun anastomosis, and the therapeutic success rate was 80%. We believe that this enterography route for ERCP is optimal for a patient who has had Billroth II gastroenterostomy and Braun anastomosis and helps to increase the success rate of the procedure.

Keywords: Billroth II; Braun anastomosis; Endoscopic retrograde cholangiopancreatography; Gastroenterostomy; Optimal enterography route.

Figure 1

The gastrojejunal anastomosis is detected at the distal end of the stomach, and 2 stomal openings corresponding to an end-to-side anastomosis can be identified endoscopically. If the efferent loop was constructed at the greater curvature of the stomach in the previous surgery, the “lower entrance” is the entrance to the right efferent loop (A). Three stomal openings can be identified endoscopically at the site of the Braun anastomosis, and the “middle entrance” leads to the appropriate loop to reach the papilla of Vater. The “middle entrance” is unique irrespective of the endoscopic approach used (B).

Figure 2

The duodenoscope should be extended along the greater curvature of the stomach and then advanced through the “lower entrance” at the site of the gastrojejunal anastomosis, along the efferent loop, and through the “middle entrance” at the site of the Braun anastomosis to reach the papilla of Vater.

Figure 3

Retrieval-balloon-assisted enterography. A catheter is advanced into the middle limb and contrast injected into the loop to confirm that the limb is the duodenal stump.