Jmv. Faylona et al., Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy, ENDOSCOPY, 31(7), 1999, pp. 546-549
Background and Study Aims: Endoscopic retrograde cholangiopancreatography (
ERCP) is one of the mainstays in the diagnosis and treatment of hepatobilia
ry and pancreatic diseases, and is also increasingly used for patients with
previous Billroth II gastrectomy. The aim of this study was to review our
experience of ERCP in patients with Billroth II gastrectomy, and the compli
cations associated with this procedure.
Patients anti Methods: The records of 110 patients with Billroth II gastrec
tomy, treated between January 1993 and December 1997, were received retrosp
ectively. Details noted included indications for ERCP, therapeutic interven
tions, causes of failure, and complications.
Results: A total of 110 patients underwent ERCP; the total number of ERCP a
ttempts was 185. The major indications for ERCP were cholangitis (31%), com
mon bile duct stones (22%), and jaundice (15%). The endoscope was successfu
lly passed up to the papilla in 134 exminations (71%), and selective cannul
ation was successful in 122 of these (66%). There were 63 (34%) failed ERCP
attempts. Causes of failure were: difficulty in entering the afferent loop
(n = 19, 10%), failure to enter the duodenum (n = 23, 12%), endoscope-rela
ted bowel perforation (n = 9, 5%), and failed cannulation (=10, 6%). The ot
her two failures were caused by desaturation in the patient, and inability
to distend the duodenum. The major complication of the procedure was perfor
ation, which occurred in 11 examinations (6%). Of these perforations, nine
occurred in the small bowel while the endoscope was being manipulated throu
gh the afferent loop; these patients required laparotomy. Two patients had
retroduodenal perforations, one occurring after sphincterotomy and one afte
r cannulation. Both patients were successfully managed conservatively. Thre
e patients suffered bleeding after sphincterotomy (3/185 procedures, 1.6%),
and one patient developed acute pancreatitis. These were managed conservat
ively. The overall complication rate was 8%. There were two deaths among th
e patients with small-bowel perforations, and consequently an overall morta
lity rate of 1% (2/185 procedures).
Conclusions: Most complications of ERCP in patients with previous Billroth
II gastrectomy were caused by bowel perforation while the endoscope was bei
ng manipulated through the afferent limb. Such perforations are intraperito
neal and require surgical intervention.