P0379 - Double Wire Cannulation and Mechanical Lithotripsy in Billroth II With Therapeutic Gastroscope

Grace Kim, MD¹, Shifa Umar, MD², Dennis Chen, MD², Uzma D. Siddiqui, MD^2
1University of Chicago, Chicago, IL; ²Center for Endoscopic Research and Therapeutics (CERT), University of Chicago, Chicago, IL

Introduction:

Billroth II reconstruction poses a unique challenge for ERCP, including cannulation due to the altered papilla orientation with the biliary orifice positioned at 5 o’clock rather than the conventional 11 o’clock in normal anatomy¹. Forward-viewing therapeutic gastroscopes have reported higher cannulation success rates than side-viewing endoscopes in this situation^1,4 but are not commonly used. We describe a case of ERCP with a forward-viewing therapeutic gastroscope with a clear distal attachment cap in a Billroth II patient with large choledocholithiasis.

Case Description/Methods: 86-year-old male with Billroth II presented at another facility with fevers and chills. Alkaline phosphatase was 664 U/L (45-117 U/L), total bilirubin 3.2 mg/dL (0.2-1.0 mg/dL), AST 123 U/L (< 40 U/L), and ALT 149 U/L (< 64 U/L). MRCP showed a large stone in the distal common bile duct (CBD) with upstream dilation. ERCP attempted twice at outside facility was unsuccessful at identifying the major papilla and the patient was referred for repeat ERCP attempt. ERCP was performed using a distal attachment cap on a forward-viewing therapeutic gastroscope. Initially the pancreatic duct (PD) was cannulated and contrast was injected. The wire was left inside the PD (figure 1a) to aid with biliary cannulation, a “double wire technique” (figure 1b). Cholangiogram showed a dilated CBD with a large 2cm stone. Biliary sphincterotomy via Billroth II sphincterotome was then performed in the 5-6 o’clock position (figure 1c) in conjunction with papillary balloon dilation. Mechanical lithotripsy using a basket was used to fragment the large stone into multiple smaller pieces  (figure 1d), then extraction balloon removed the fragments to achieve biliary clearance. Lastly, a single pigtail 5 Fr x 3cm plastic PD stent was placed to mitigate post-procedural pancreatitis risks (figure 1e). No complications ensued.

Discussion:

Using a forward-viewing therapeutic gastroscope is safe and effective for biliary cannulation in surgically altered anatomy such as Billroth II. Distal attachment cap enables better visualization of the papilla. Special considerations such as the reversed caudal direction of the biliary orifice should be recognized with Billroth II, which necessitates alternative devices and techniques for cannulation and sphincterotomy. Standard ERCP precautions such as PD stent placement after PD cannulation and injection should still be undertaken for post ERCP pancreatitis prophylaxis.

 

Disclosures:


Grace Kim, MD¹, Shifa Umar, MD², Dennis Chen, MD², Uzma D. Siddiqui, MD². P0379 - Double Wire Cannulation and Mechanical Lithotripsy in Billroth II With Therapeutic Gastroscope, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.