Digestive Endoscopy Unit, Catholic University, Gemelli University Hospital, Rome, Italy.
Digestive Endoscopy Unit, Niguarda Hospital, Milan, Italy.
Endoscopy. 2015 Jul;47(7):611-6. doi: 10.1055/s-0034-1391567. Epub 2015 Mar 2.
Endoscopic retrograde cholangiopancreatography (ERCP) is difficult in patients with altered anatomy following Billroth II gastrectomy. Afferent loop intubation, selective cannulation, and sphincterotomy are the main issues. Experience from a tertiary referral endoscopy center is reported.
A total of 713 patients with Billroth II reconstruction who underwent ERCP between October 1982 and October 2012 were retrospectively identified from a prospectively collected database (mean age 69 ± 27 years; 567 males). The main indications for ERCP were common bile duct stones (51.2 %) and obstructive jaundice (24.8 %). Procedures were always started with a duodenoscope; in cases of failure to reach the papilla the duodenoscope was changed to a gastroscope. Endoscopic sphincterotomy was performed using a long-nose sigmoid inverted sphincterotome.
The successful duodenal intubation rate was 86.7 % (618/713 patients). The main reason for intubation failure was a long and angulated afferent loop. Successful cannulation/opacification of the desired biliopancreatic duct was 93.8 % (580/618). Biliary and/or pancreatic sphincterotomy were performed in 490 (84.5 %) and 23 (4.0 %) patients, respectively. The adverse event rate was 4.3 % (45/1050 procedures). Peritoneal perforation occurred in 1.8 % of the cases (19/1050 procedures) and always required immediate surgery. Two patients died after surgery (overall mortality 0.3 %). The other adverse events resolved following conservative management or endoscopic reintervention.
In experienced centers, ERCP in Billroth II patients had morbidity and mortality rates that were comparable to patients with normal anatomy. The main reasons for failure were related to the inability to reach the papilla. Peritoneal perforation was the most common adverse event, and required a prompt surgical approach.
毕罗氏Ⅱ式胃切除术后解剖结构改变的患者行内镜逆行胰胆管造影术（ERCP）较为困难。主要问题包括输入襻插管、选择性胆管插管和括约肌切开术。本文报道了一家三级转诊内镜中心的经验。
从一个前瞻性收集的数据库中回顾性确定了 1982 年 10 月至 2012 年 10 月间行 ERCP 的 713 例毕罗氏Ⅱ式重建患者（平均年龄 69±27 岁；567 例男性）。ERCP 的主要适应证为胆总管结石（51.2%）和梗阻性黄疸（24.8%）。所有操作均从十二指肠镜开始；如果无法到达乳头，则将十二指肠镜更换为胃镜。采用长鼻型反向乙状结肠切开刀进行内镜下括约肌切开术。
十二指肠插管成功率为 86.7%（618/713 例）。插管失败的主要原因是输入襻过长和迂曲。580/618 例患者成功地对预期的胆胰管进行了插管/显影。490（84.5%）例患者行胆管和/或胰管括约肌切开术，23（4.0%）例患者行内镜下括约肌切开术。不良事件发生率为 4.3%（45/1050 例）。腹膜穿孔发生率为 1.8%（19/1050 例），均需立即手术。术后 2 例患者死亡（总死亡率 0.3%）。其他不良事件经保守治疗或内镜再介入后得到解决。
在有经验的中心，毕罗氏Ⅱ式患者的 ERCP 并发症发生率和死亡率与正常解剖结构的患者相当。失败的主要原因与无法到达乳头有关。腹膜穿孔是最常见的不良事件，需要及时进行手术治疗。
