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ERCP in Surgically Altered Anatomy

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ERCP for surgically altered anatomy in Billroth II (gastrojejunostomy)

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure with which your doctor can look at the pancreatic duct and the bile duct in your body. They are located close to your stomach. Both these ducts take digestive juices, from your pancreas and liver respectively, to the intestines.

Billroth II (Billroth’s operation II/BII) is a procedure that is performed for partial removal of your stomach (partial gastrectomy). When performed, the cut end of the stomach is closed. Then, your stomach’s greater curvature is connected to the jejunum’s first part by performing an end-to-side anastomosis. Billroth II is used for resection of the lower part of your stomach (Antrim).

You might need to undergo a Billroth II reconstruction procedure, usually in one of the following situations: in complications of peptic ulcer disease (perforation, bleeding, penetration, duodenal stricture), in gastric carcinoma localized to the antrum or in distal stomach resection reconstruction.

Challenges faced while performing post-Billroth II (gastrojejunostomy) ERCP

ERCP becomes challenging if you have undergone surgery and have an ‘altered surgical anatomy’. Some of these challenges faced by doctors are:

  • Which is the appropriate endoscope and its accessories for performing the ERCP.
  • Accessing the intestinal limb harbouring the pancreatic orifice and papilla
  • Arriving at the ampullary opening
  • Cannulating the papilla from a nonstandard position
  • Conducting the endoscopic therapy

What information is required before performing ERCP in a patient who has undergone Billroth II (gastrojejunostomy)

  • Anatomic resection
  • Type of reconstruction
  • Length of the limbs
  • Type of anastomosis (side-to-side or end-to-side)
  • Postoperative gastrointestinal (GI) imaging studies
    • Abdominal computed tomography (CT) examinations
    • Magnetic resonance imaging (MRI)
    • Upper GI (UGI) series
  • Time interval since the surgery

What to do before ERCP

The benefits and associated risks of the procedure will be clearly explained to you by the surgeon who is to perform your ERCP. You will need to declare in writing that you understand what the procedure entails and consent to the procedure being performed on you.

While pre-procedure instructions can be more specific to your listed below are some of the general instructions:

  • Stop your food and water intake as advised by the doctor.
  • You may have medications your doctor told you are allowed. Take very little water with the medicines.
  • Your doctor might stop some of your regular medicines associated with the immune system before the surgery.
  • Inform the doctor about any shellfish or iodine allergy.

What alternatives are there to ERCP

ERCP is the most preferred procedure as it is the least invasive and comes with a high success rate. Yet, you could go for any of the following:

  • Radiology procedures
  • More advanced laparoscopic surgical procedures

If you have had bariatric surgery to treat for overweight, it is very much possible that it was a Roux-en-Y gastric bypass (RYGB). In which case, it will be a challenge for your doctor to perform the ERCP procedure for you because of the long Roux limb. Do not worry, as ERCP is not the only option. You could go in for an enteroscopy (DBERCP). This procedure is used to examine your small bowel with the help of an enteroscope, a thin, flexible tube to which a camera is attached.

Also, post your gastric bypass surgery, if you face issues with the bile duct, gall bladder or pancreas, Endoscopic ultrasound Directed transGastric ERCP (EDGE) might be the procedure for you.

What to Expect During the ERCP

ERCP will be performed on you in a hospital or a doctor’s clinic. It can be either performed on you under:

  • Sedation or
  • General anaesthesia

To perform the ERCP procedure, a flexible, lighted tube (endoscope/scope) is used by your doctor. Once the scope is in place, the doctor inserts a thin, flexible plastic tube through it. Through this tube, a dye is injected into you and is visible on X-rays. In this way, your doctor can see your ducts and assess their functioning. Just before starting the ERCP procedure, your throat might be made numb by spraying a local anaesthetic. This will keep you comfortable and prevent choking or gagging when the scope is inserted through your mouth. They will use an IV to give you sedative medicine. If you are given general anaesthesia for the ERCP procedure, you will not remain awake.

While you lie on an x-ray enabled table, your doctor will send the scope via your mouth, throat (oesophagus), stomach to your small intestine (duodenum) first part.

The ERCP procedure generally takes between half an hour to one hour. But based on what your doctor is looking for or needing to do, the procedure could get done sooner or take longer.

What to expect post ERCP

Your doctor could keep you in the hospital overnight for observation or let you go the same day.

If you can go home the same day, you will need to stay back till your sedatives wear off. You need to be driven home by a responsible person. You must rest, eating normally and taking your regular medication unless otherwise advised by your doctor.

Please note that for the next few days, you could suffer from a sore throat.

How long does it take for ERCP results?

Generally, you can get the result from your doctor the day the procedure is performed. If the test has to be done by a laboratory, it will take longer.

ERCP complications

Though in the hands of a trained doctor, ERCP complications do not happen yet, some rare complications are possible. :

  • The Pancreatitis condition that occurs is if your pancreatic duct gets irritated by the dye used for the X-ray or the plastic tube used at the time of your procedure. It leads to stomach ache that worsens post-procedure.
  • If treatment was performed on you during your ERCP, for example, inserting a stent or removing stones, it could lead to bleeding or causing the bile duct or intestine to develop a hole.
  • Rarely encountered, but you could catch an infection transmitted from the scopes.

Signs to watch out for post ERCP

  • Severe abdominal pain
  • Blood in your stool
  • Nausea and vomiting
  • Fever
  • Chills
  • Vomiting

If any of these happen, contact your doctor.

Conclusion

ERCP has an increasingly vital role in managing any complications that might arise post your Billroth II surgery. When an expert performs with all vital information at hand, the chances of success are extremely high. ERCP has become a boon for those who have undergone bariatric procedures with the ever-evolving technology and technique. If you face any post-Billroth II complications, do not hesitate to reach out to your doctor and look at ERCP as your option.