Easy sphincterotomy in patients with Billroth II gastrectomy: a new technique

ERCP and endoscopic sphincterotomy in patients with Billroth II gastrectomy are technically more difficult due to the reversed anatomy. We developed a new guidewire sphincterotome that includes two 15-mm non-isolated metal parts, one of which is located 12 cm from the distal tip and the other in the proximal end. The aim of this study was to evaluate the feasibility of and outcomes with the new sphincterotome for sphincterotomy in patients with Billroth II gastrectomy.

Between January 2004 and March 2007, 11 patients with Billroth II gastrectomy underwent endoscopic sphincterotomy with the new guidewire sphincterotome. Procedures were initiated by deep cannulation of the bile duct with a standard catheter and guidewire sphincterotome. After cholangiography, the catheter was withdrawn with 0.5 to 1 cm of its tip outside the duodenoscope. The distal non-isolated part of the sphincterotome was placed in the papillary orifice. In order to reach the proper position, the duodenoscope's elevator was moved to the downward position, the up-down dial was turned slightly in the downward direction, and then the duodenoscope was pushed slightly forward. Finally, sphincterotomy was performed in the 6 o'clock direction.

Sphincterotomy with the new sphincterotome was successfully achieved in all patients without using protective pancreatic stents. Seven patients had common bile duct stones, two pancreatitis, one odditis, and another one persistent bile duct leakage. There were no sphincterotomyrelated complications or death during this study.

In this pilot study, endoscopic sphincterotomy with a new guidewire sphincterotome in patients with Billroth II gastrectomy was found to be clinically successful, concise, easy to perform, efficient, and reliable. However, further large comparative studies are needed for a definite conclusion.