Endoscopic retrograde cholangiopancreatography and endoscopic transpapillary management
of bile duct stones is more difficult in patients with a Roux-en-Y anastomosis than
it is in patients with Billroth II reconstructions because of differences in the postoperative
anatomy. Two patients, a 48-year-old man (patient 1) and a 74-year-old man (patient
2), who had both undergone a total gastrectomy and Roux-en-Y anastomosis for gastric
carcinoma, were admitted to our hospital for endoscopic treatment of common bile duct
(CBD) stones. In both cases, a pediatric colonoscope (PCF-230; Olympus, Tokyo, Japan)
was inserted into the Roux-en-Y limb up to the papilla. Endoscopic retrograde cholangiography
revealed CBD stones with diameters of less than 10 mm. Neither conventional sphincterotomes
nor needle-knives could be safely positioned to perform endoscopic sphincterotomy
(ES) in these patients. We therefore attempted to demonstrate that endoscopic papillary
balloon dilation (EPBD) could be used as an alternative to ES. A balloon dilator (Max-Force
Balloon Dilator; Microvasive, Boston Scientific Corporation, Watertown, USA) was passed
over the guide wire and into the common bile duct. The balloon was inflated to a diameter
of 8 mm and a pressure of 3 atmospheres for 1 minute (Figure [1]). After EPBD, the stones were successfully extracted in both cases using a conventional
basket catheter in a single procedure (Figure [2]). There were no major complications. Although several techniques are available for
performing ES in patients who have previously undergone Roux-en-Y anastomosis [1]
[2]
[3], it is not easy to maneuver the sphincterotome through a forward-viewing endoscope
that has a long working length, such as the pediatric colonoscope. Compared with ES,
the technical advantage of EPBD is the ease with which the opening of the bile duct
can be enlarged without the need for fine control of the sphincterotome and endoscope.
For this reason, EPBD has already been applied in endoscopic explorations for bile
duct stones in patients who have had a Billroth II gastrectomy [4]
[5]. In conclusion, EPBD appears to be particularly useful for managing bile duct stones
in patients who have had a Roux-en-Y reconstruction.
Figure 1 Endoscopic papillary balloon dilation in a 48-year-old man (patient 1) who had undergone
a total gastrectomy and Roux-en-Y anastomosis. The cholangiogram shows the inflated
balloon dilator (arrow) and the inset shows the endoscopic view.
Figure 2 Fluoroscopic view of stone extraction using a conventional basket catheter after endoscopic
papillary balloon dilation in patient 1. The arrow points to the common bile duct
stones caught in the basket catheter.
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