ENDOSCOPIC ACCESS TO THE PAPILLA OF VATER FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH BILLROTH-II OR ROUX-EN-Y GASTROJEJUNOSTOMY

Background and Study Aims: Endoscopic retrograde cholangiopancreatogra phy (ERCP) is an established modality for the diagnosis and treatment of pancreaticobiliary disorders. In contrast to ERCP in patients who h ave not undergone gastrectomy, ERCP in patients with a Billroth II gas trojejunostomy or a Roux-en-Y anastomosis is considerably more difficu lt. It was nevertheless considered that ERCP might be possible in most patients with gastrectomies, and this hypothesis was tested. Patients and Methods: A total of 2256 patients were admitted to our hospital f or ERCP from 1990 to 1994. Of these, 65 (3%) had gastrojejunostomies, either with Billroth II reconstructions or with the Roux-en-Y procedur e. ERCP was always performed with a conventional side-viewing endoscop e. Results: We examined the 65 patients with gastrojejunostomies. Of t hese, 91% had Billroth II anastomoses and 9% had received Roux-en-Y re constructions. We successfully reached the papilla of Vater with the e ndoscope in 92% of the patients with Billroth II gastrojejunostomies ( 54 of 59), but in only 33% of the patients with Roux-en-Y reconstructi ons (two of six). In 8% of the cases of Billroth II anastomosis, it wa s not possible to advance the endoscope into the duodenal stump, due t o intestinal stenoses (5%) or excessive intestinal length (3%). Failur e in case of regular Billroth II anatomy occured only in patients who had not received Braun enteroenterostomies. Failure also occured in 67 % of the Roux-en-Y gastrojejunostomy cases due to excessive intestinal length. Conclusions: Most patients with Billroth II gastrojejunostomy (92% of those in the present study) and some patients with Roux-en-Y anastomosis (33% of those in the present study) can be investigated by ERCP and endoscopically treated in cases of pancreaticobiliary disord er. Braun enteroenterostomy has no negative impact on the endoscopic a ccess to the papilla of Vater in patients with Billroth II gashtrojeju nostomy. Surgical reconstruction of the gastrointestinal tract to perf orm gastrojejunostomy should also take endoscopic requirements into ac count. In view of both the potential postoperative complications and e ndoscopic requirements, the jejunojejunostomy should be placed nearer to the gastrojejunostomy than 60 cm, and the afferent loop should be a s short as possible.