Recent advances in endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: A systematic review

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy has been considered a challenging procedure due to the surgically altered gastrointestinal anatomy. However, there has been a paucity of comparative studies regarding ERCP in Billroth II gastrectomy cases because of procedure-related morbidity and mortality and practical and ethical limitations. This systematic and comprehensive review was performed to obtain a recent perspective on ERCP in Billroth II gastrectomy patients.

Aim: To systematically review the literature regarding ERCP in Billroth II gastrectomy patients.

Methods: A systematic review was performed on the literature published between May 1975 and January 2019. The following electronic databases were searched: PubMed, EMBASE, and Cochrane Library. The outcomes of successful afferent loop intubation and successful selective cannulation and occurrence of adverse events were assessed.

Results: A total of 43 studies involving 2669 patients were included. The study designs were 36 (83.7%) retrospective cohort studies, 4 (9.3%) retrospective comparative studies, 2 (4.7%) prospective comparative studies, and 1 (2.3%) prospective cohort study. Of a total of 2669 patients, there were 1432 cases (55.6%) of side-viewing endoscopy, 664 (25.8%) cases of forward-viewing endoscopy, 171 (6.6%) cases of balloon-assisted enteroscopy, 169 (6.6%) cases of anterior oblique-viewing endoscopy, 64 (2.5%) cases of dual-lumen endoscopy, 31 (1.2%) cases of colonoscopy, and 14 (0.5%) cases of multiple bending endoscopy. The overall success rate of afferent loop intubation was 91.3% (2437/2669), and the overall success rate of selective cannulation was 87.9% (2346/2437). A total of 195 cases (7.3%) of adverse events occurred. The success rates of afferent loop intubation and the selective cannulation rate for each type of endoscopy were as follows: side-viewing endoscopy 98.2% and 95.3%; forward-viewing endoscopy 97.4% and 95.2%; balloon-assisted enteroscopy 95.4% and 97.5%; oblique-viewing endoscopy 94.1% and 97.5%; and dual-lumen endoscopy 82.8% and 100%, respectively. The rate of bowel perforation was slightly higher in side-viewing endoscopy (3.6%) and balloon-assisted enteroscopy (4.1%) compared with forward-viewing endoscopy (1.7%) and anterior oblique-viewing endoscopy (1.2%). Mortality only occurred in side-viewing endoscopy (n = 9, 0.6%).

Conclusion: The performance of ERCP in the Billroth II gastrectomy population has been improving with choice of various type of endoscope and sphincter management. More comparative studies are needed to determine the optimal strategy to perform safe and effective ERCP in Billroth II gastrectomy patients.

Keywords: Adverse event; Billroth II operation; Cholangiopancreatography; Endoscope; Endoscopic retrograde; Systematic review; Therapeutic.

Figure 1

Flow diagram of the study. ¹Case report (n = 28), review (n = 15), abstract (n = 13), letter (n = 7), and commentary (n = 6).

Figure 2

Side-viewing endoscopy. A: Naïve papilla; En face view can be obtained with ease. The direction of bile duct is reversed (arrow); B: Selective cannulation can be achieved with assistance of elevator; C: Sphincter management with papillary balloon dilation; endoscopic view; D: Sphincter management with papillary balloon dilation; fluoroscopic view; E: Common bile duct stone was removed by basket.

Figure 3

Cap-fitting forward-viewing endoscopy. A: Naïve papilla; It is difficult to obtain en face view. The direction of bile duct is reversed (arrow); B: Gastroscope of 7 o’clock position working channel; Sphincter management with inverted sphincterotome; C: Pediatric colonoscope of 5 o’clock position working channel; D: Endobiliary biopsy was performed in distal common bile duct stricture; E: Bilateral uncovered metal stents were inserted in the malignant hilar stricture.