Rotatable Sphincterotome Facilitates Bile Duct Cannulation in Patients With Altered Ampullary Anatomy

Abstract

In patients who have undergone prior Billroth-II (B-II) anastomosis, endoscopic retrograde cholangiopancreatography (ERCP) is challenging due to altered duodenal anatomy, which requires use of customized sphincterotomes. We report the use of a standard rotat-able sphincterotome for successful cannulation in 5 patients with prior B-II gastrojejunostomy and 1 patient with choledochoduodenostomy. In our experience, cannulation and endoscopic intervention were successfully accomplished in all patients without any complications. Although retrospective case series analysis limits the conclusiveness of our findings, we believe that a rotatable sphincterotome can be successfully utilized to cannulate the common bile duct in patients with prior B-II anastomosis, thereby eliminating the need to maintain an inventory of specialized accessories.

Cannulation of the biliary and/or pancreatic duct in patients with prior Billroth-II (B-II) anastomosis necessitates the use of customized sphincterotomes with a reverse bow, due to the altered anatomy of the ampulla and pancreaticobiliary ducts. In such patients, orientation of the bile duct is reversed as the endoscope approaches the papilla from below instead of above, and the cannulation technique must be modified accordingly (Figure 1). The standard sphincterotome is not suitable for cannulation and sphincterotomy in B-II patients, as the cutting wire is directed towards the posterior wall of the duodenal stump. Hence, operators tend to use a straight sphincterotome or other specialized B-II accessories. The B-II sphincterotome has a cutting wire oriented in the reverse position of the standard sphincterotome.¹ Costamagna and associates,² among others,³ have devised a sphincterotome that is a sigmoid-shaped catheter with a long distal tip for deep cannulation into the common bile duct. Although sphincterotomes that accommodate the B-II orientation are commercially available, they are not stocked in every endoscopy unit and as a result may not be available for immediate use. These sphincterotomes are often more expensive than conventional accessories. We analyzed a retrospective cohort of 5 patients with prior gastrectomy and B-II anastomosis and 1 patient with choledochoduodenostomy to determine the feasibility of performing therapeutic intervention using a standard rotatable sphincterotome.

Figure 1.

Endoscopic view of the major papilla in a patient with prior Billroth-II anastomosis.

Patients and Methods

Clinical data and outcomes of 6 patients with prior gastrectomy and B-II anastomosis who had previously undergone endoscopic retrograde cholangiopancreatography (ERCP) were reviewed. Patient demographics, clinical indications, and outcomes are compiled as per Table 1. Consensus guidelines were utilized for definitions of complications related to ERCP, including pancreatitis, bleeding, and perforation. All patients had undergone ERCP using a standard technique. Briefly, following sedation using intravenous propofol, the duodenoscope was carefully advanced into the afferent loop, and the major papilla was identified and cannulated using the Autotome Rx 49 (Boston Scientific). The autotome has a 20-mm cutting wire, 5 Fr tip, and 5-mm tip length sphincterotome with the ability to rotate the tip and change its orientation in relation to the papilla (Figure 2). This rotation allows the endoscopist to cannulate the desired duct and perform sphincterotomy in the opposite direction from that performed in patients with normal anatomy (Figures 3–5). Prior to use, the sphincterotome was trained by bending the tip in the expected orientation of the bile duct at a 5–6 o'clock position. Once in the accessory channel of the endoscope, turns of the sphincterotome handle may not be transmitted to the tip of the autotome in a 1:1 ratio. Pulling and pushing the sphincterotome back and forth in the channel (wiggling) and straightening the endoscope to the greatest extent possible facilitates transmittal of the torque to the tip of the autotome. Straightening of the endoscope may be achieved by turning the small wheel counterclockwise to the greatest extent possible without losing ampullary view. Silicone or lubrication jelly may also be used to lubricate the accessory channel to facilitate rotation of the autotome within the accessory channel.

Table 1.

Patient Characteristics

Patient	Age/Sex	Indication	Intervention	Diagnosis	Complications
1	42/M	Jaundice	ES, CBD dilation, and plastic stent	CBD stricture	None
2	71/F	Painless jaundice	ES, plastic stent	Pancreatic head cancer	None
3	38/M	Jaundice	ES, stone extraction	CBD stone	None
4	44/M	Jaundice	ES, stone extraction	CBD stone	None
5	75/M	Cholangitis	ES, stone extraction	CBD stone	None
6	69/M	Right upper quadrant pain	ES, stone extraction	CBD stone	None

ES

endoscopic sphincterotomy

CBD

common bile duct.

Figure 2.

Rotation of the standard autotome orients the tip of the cannula to the correct position.

Figure 3.

Deep cannulation of the papillary orifice using a standard rotatable autotome.

Figure 4.

Biliary sphincterotomy using a standard rotatable autotome.

Figure 5.

Common bile duct stone extraction using a basket, following common bile duct cannulation in a patient with prior Billroth-II anastomosis.

Results

Of the 6 patients, 5 had prior gastrectomy and B-II anastomosis whereas 1 had prior choledochoduodenostomy. Indications included four common bile duct stones, 1 common bile duct stricture, and 1 pancreatic head cancer. Cannulation and interventions were successfully carried out in all patients without any complications.

Discussion

Over 3% of all patients undergoing ERCP have prior history of B-II anastomosis. Furthermore, patients with prior B-II anastomosis have a greater likelihood of having choledocholithiasis. Performing therapeutic ERCP in B-II patients is often challenging. In a retrospective analysis of patients with prior history of B-II undergoing ERCP, indications included choledocholithiasis in 64%, papillary stenosis in 17%, and malignant tumors in 14%.⁴ Osnes and associates⁴ and Forbes and colleagues⁵ have reported that therapeutic ERCP in B-II patients involves a higher frequency of repeated attempts, pre-cut techniques, and possibly severe complications. In a retrospective review of 4,374 ERCP procedures performed between 1971 and 1982, 63 patients had prior B-II gastrectomy; cannulation of the pancreatic biliary duct was unsuccessful in approximately half of patients, and this failure was attributed to the inability to direct the sphincterotome to the correct orientation in several patients.⁶ In another retrospective review involving 4,967 ERCP procedures performed between 1980 and 1984, 147 patients had prior B-II anastomosis, and cannulation was unsuccessful in 13 of these patients. Endoscopic sphincterotomy was indicated in 50 patients, of whom 46 were for choledocholithiasis and 4 were for malignant obstruction. In 2 patients, it was impossible to orient the sphincterotome for adequate sphincterotomy and in another 2 patients, there was significant bleeding following sphincterotomy, which prevented further intervention. Among the remaining 46 patients, a specialized papillotome (30–30 papillotome) was employed in 28 patients, suprapapillary papillotomy was performed in 15 patients, and 3 patients underwent precut sphincterotomy. Complications occurred in 3 patients: 1 patient died after a duodenal perforation, 1 died after bleeding from a sphincterotomy site, and 1 developed pancreatitis 1 week after biliary sphincterotomy.

The traditional sphincterotome is designed to perform sphincterotomy at the 12 o'clock orientation. However, in patients with B-II anatomy, the sphincterotomy needs to be oriented in the 6 o'clock direction.^6–8 Although various techniques and specialized endoscopic accessories have been developed to facilitate cannulation in B-II patients, these accommodations may be more expensive and are often not readily available in endoscopy units. In the present study, we demonstrate the feasibility of using a standard rotatable sphincterotome for common bile duct cannulation followed by therapeutic intervention, which was successful in all patients as a single step. Shah and coworkers⁸ have also reported in abstract form their experience with a rotatable sphincterotome and concluded that a rotatable papillotome allows successful cannulation, sphincterotomy, and selective guidewire placement in patients with altered surgical anatomy and intrahepatic diseases. In conclusion, we propose the use of a rotatable sphincterotome for ERCP in B-II patients or when cannulation/therapeutic interventions entails orientation other than the standard 11–1 o'clock position.