Retrospective Study Of Endoscopic Retrograde Cholangiopancreatography In Billroth Ⅱ Gastrectomy Patients

Objective: To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography(ERCP)in the diagnosis and treatment of patients with biliary and pancreatic diseases after Billroth Ⅱ(B Ⅱ)gastrectomy,to indentify the risk factors affecting its procedural failure and complications,and to preliminarily investigate the learning curve of B Ⅱ ERCP.Methods: The clinical data of patients after B Ⅱ gastrectomy treated by ERCP from August 1998 to December 2017 in the Digestive Endoscopy Center of Shanghai Changhai Hospital were retrospectively analyzed.The procedural success rate and complication rate of B Ⅱ ERCP were summarized.Logistic regression analysis was used to indentify the independent risk factors affecting procedural failure and complications,and the learning curve of B Ⅱ ERCP was preliminarily investigated based on the cumulative technical success rate.Results: The success rates of ampullary access,selective cannulation and clinical therapeutic intervention of B Ⅱ ERCP were 81.9%(345/421),86.4%(298/345)and 93.6%(279/298),respectively.The technical success rate was 70.8%(298/421)and the total success rate was 69.1%(291/421).The single-session clearance rate of common bile duct(CBD)stones was 59.7%(105/176),and the ultimate clearance rate of CBD stones was 77.8%(137/176).The incidence of ERCP-related complications was 15.7%(66/421),and the incidence of post-ERCP pancreatitis(PEP)was 3.1%(13/421).In multivariate analysis,first ERCP session [odds ratio(OR)=4.950,95% confidence interval(CI): 2.037-12.031,P<0.001],Braun anastomosis(OR=5.306,95% CI: 1.879-14.979,P=0.002)and no cap-fitted gastroscope(OR=2.783,95% CI: 1.399-5.536,P=0.004)were risk factors for failed ampullary access;first half procedures(OR=3.410,95% CI: 1.742-6.672,P<0.001)was a risk factor for failed selective cannulation,and the use of side-viewing duodenoscope(OR=0.187,95% CI: 0.055-0.641,P=0.008)was a protective factor for successful selective cannulation;CBD stone number ≥ 2(OR=2.447,95% CI: 1.210-4.946,P=0.013)and the largest CBD stone size ≥ 12mm(OR=3.800,95% CI: 1.881-7.676,P<0.001)were risk factors for failed stone removal,and the use of EPBD or EPLBD(OR=0.321,95% CI: 0.159-0.648,P=0.002)was a protective factor for successful stone removal.Age < 50 years(OR=5.113,95% CI: 1.379-18.954,P=0.015)and cannulation using another guidewire(OR=5.226,95% CI: 1.525-27.912,P=0.009)were risk factors for PEP;first ERCP attempt(OR=5.527,95% CI: 1.838-16.614,P=0.002)and the use of mechanical lithotripsy(OR=3.751,95% CI: 1.051-13.383,P=0.042)were risk factors for asymptomatic hyperamylasemia.Based on the cumulative technical success rate,it was estimated that the minimum number of procedures for advanced trainees required to achieve a technical success rate of 80% was 20.Conclusions: ERCP is safe,effective and feasible for B Ⅱ gastrectomy patients,the success rate is increasing year by year,and the incidence of complications is low and acceptable.First ERCP session,Braun anastomosis,first half procedures,and the use of a cap-fitted gastroscope or side-viewing duodenoscope are predictive factors for technical success.The number and the largest size of CBD stones,and the use of EPBD or EPLBD are predictive factors for stone removal.Special attention should be paid to the possible occurence of related complications in patients with younger age,cannulation using another guidewire,and first ERCP attempt or the use of mechanical lithotripsy.To achieve a cumulative technical success rate of 80%,at least 20 B Ⅱ ERCP sessions should be performed by advanced trainees.