EUS-DIRECTED TRANSGASTRIC ERCP IN A BILLROTH II GASTRECTOMY BY USING LUMEN-APPOSING METAL STENT

In Billroth II anatomy, ERCP is challenging. Intubation of the afferent limb is sometime imposible due to an acute angle or long afferent limb.

We present a patient with Billroth II gastrectomy admitted due to biliary sepsis secondary to choledocholithiasis. The afferent limb was not accessible with the duodenoscope and gastroscope, due to acute angle for accesing the afferent limb and for long afferent loop. A nasobiliary catheter was inserted into the afferent limb and contrast, physiological and methylene blue were instilled to distend the afferent limb.

By means of endoscopic ultrasound, a portion of the loop near the gastric lumen was located, confirming by needle puncture and guidewire, which corresponds to the part closest to the papillary area. EUS-guided gastrojejunostomy was performed with a 15 × 10 mm Hot Axios stent. Subsequently, an ERCP was performed advancing the duodenoscope through the axios to the afferent limb, cannulating with double guidewire technique. During the extraction of a stone, it was impacted in the papilla. Electrohydraulic lithotripsy (EHL) was performed by introducing the Autolith probe through an extractor balloon. The fragmentation of the stones was completed by cholangioscopy with SpyGlass and EHL.

Conclusions:

There are no previously described cases of gastroenteroanastomosis bridge in patients with Billroth II for the performance of ERCP. This procedure is feasible with lumen-apposing metal stent and may be useful in some cases in which the afferent limb can not be accessed.