Mission (nearly) impossible: ERCP using an oblique cap with suction cannulation in a diffusely strictured duodenal stump after Billroth II with Braun enteroenterostomy
17 September 2019 (online)
This is a unique clinical report of an 82-year-old man with cholangitis post distal gastrectomy for treatment of ulcer disease > 35 years ago, with no operative report available.
The patient was referred subacutely for ERCP, which could not be performed in the primary hospital owing to unclear anatomy. First using a forward-viewing colonoscope in the left-lateral position, a jejunal limb was readily reached via the lesser curvature, with a second lumen identifiable at the opposite side, suggesting Billroth II anatomy . Further advancement of the scope revealed a putative Braun’s enteroenterostomy; however, the expected third lumen was not readily identifiable. On further scrutiny, convoluted folds near the suture line came to our attention, and after mounting a cap, the apparently degenerated duodenal stump with a sharp angulation could be carefully entered with a visibly dilatory effect. The entire duodenal stump proved diffusely strictured, such that we switched to a cap-fitted gastroscope to limit perforation risks . Cautious and patient push-and-pull movements with intermittent abdominal compression were needed to finally reach the papilla in a strictly tangential position ([Fig. 1], [Video 1]). With a view to the ensuing utterly limited scope maneuverability and stability, we again exchanged for a double-lumen gastroscope with an oblique cap attached, with the shorter axis oriented to the papilla to better align into the putative biliary axis. Next, we applied a suction-assisted cannulation approach with a straight catheter, readily enabling deep biliary access, and multiple distal bile duct stones were confirmed ([Fig. 2], [Video 1]). The patient underwent endoscopic papillary balloon dilation up to 8 mm without endoscopic papillotomy, and partial stone extraction was performed using a wire-guided basket . Given an already high demand on analgosedation, we opted for temporary bile duct stenting, inserting a 10-Fr double-pigtail stent and postponing complete stone clearance for another ERCP session.
Video 1 Access to the papilla and successful biliary intervention in a degenerated duodenal stump with diffuse stricturing after Billroth II with Braun enteroenterostomy.
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