ENDOSCOPIC SPHINCTEROTOMY USING AN S-SHAPED SPHINCTEROTOME IN PATIENTS WITH A BILLROTH-II OR ROUX-EN-Y GASTROJEJUNOSTOMY

Background and Study Aims: Some patients admitted for endoscopy presen t a gastrojejunostomy with a Billroth II anastomosis or Roux-en-Y reco nstruction. The gastrointestinal reconstruction hampers endoscopic dia gnosis and treatment of the biliary and pancreatic tract. The present paper describes a new procedure facilitating endoscopic retrograde cho langiopancreatography (ERCP) in patients who have undergone gastrojeju nostomy. Patients and Methods: ERCP was attempted in 65 patients with gastrojejunostomy. A conventional side-viewing endoscope was advanced into the duodenal stump, and a modified catheter was pushed through th e endoscope. The cutting wire of the modified catheter winds round the catheter at a pivotal point between the catheter's proximal and dista l holes. This allows the catheter tip to be forced into an S-shape whe n the wire is pulled. Since the cutting wire can easily be adjusted to the papillary roof, safe and successful endoscopic sphincterotomy can be carried out. Results: We were able to advance the conventional sid e-viewing endoscope into the duodenal stump in 92% of the patients (n = 59) with Billroth II gastrojejunostomies, and in 33% of the patients (n = 6) with Roux-en-Y anastomoses. Whenever it was possible to reach the duodenal stump, cannulation and sphincterotomy of the papilla of Vater was successful. Ninety-six percent of the patients who underwent sphincterotomy (n = 54) immediately benefited from biliary decompress ion. One major complication occurred, with a patient suffering a retro peritoneal perforation during endoscopic sphincterotomy; the patient l ater died, despite three subsequent surgical operations. Conclusions: In spite of previous gastrojejunostomy, most patients with Billroth II anastomoses (92%) and many patients with Roux-en-Y reconstructions (3 3%) can be treated endoscopically for biliary diseases. The use of a c onventional side-viewing endoscope in conjunction with an S-shaped sph incterotome can be recommended. This allows safe and successful endosc opic treatment of all patients in whom endoscopic access to the papill a of Vater is possible.