Shinshu M ed J, 63⑹ :385〜389, 2015

Endoscopic Retrograde Cholangiopancreatography
Using a Multi‑bending Duodenoscope in Patientswith a Billroth I Gastrectomy
Norikazu ARAKURA , Tetsuya ITO , Eiji TANAKAand Takeji UMEMURA
1) Endoscopic Examination Center, Shinshu University Hospital2) Department of Medicine, Shinshu University School of Medicine

Aims:We assessed the success rate at our endoscopic center in patients with a Billroth I gastrectomy andcompared it to the rate in patients without a gastrectomy,retrospectively,and assessed the clinical utility ofa multi‑bending duodenoscope for bile duct cannulation in patients with a Billroth I gastrectomy.
Patients and Methods:Six‑hundred and twentypatients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with the use of a conventional single‑bending duodenoscope and 26 patients whounderwent ERCP with a multi‑bending duodenoscope were enrolled.Of the 620 patients,560 had no history ofgastrectomyand the remaining 60 had had a Billroth I gastrectomy.The latter 26 patients included six patients
whose bile duct cannulation was unsuccessful by conventional endoscope (three of whom were withoutgastrectomy and the other three had had a Billroth I gastrectomy).
Results:The success rate of bile duct cannulation in the patients who underwent ERCP with the conventional
duodenoscope was higher in those without gastrectomy (89 %) than in those with a Billroth I gastrectomy(85%), but the diﬀerence was not signiﬁcant. Bile duct cannulation was successful with the multi‑bending
duodenoscope in all three patients with a Billroth I gastrectomy whose previous cannulation by conventional
endoscopy was unsuccessful. In contrast, the cannulation was not successful in all three patients without
gastrectomy whose previous cannulation was unsuccessful by conventional endoscopy.The success rate in the20 naive patients without gastrectomy was 95% by multi‑bending duodenoscope.The incidence of post‑ERCP
pancreatitis was similar between the patients with the use of the single‑ (7.6%) and multi‑bending (7.7%)
duodenoscopes.
Conclusion :Our preliminary data suggest that the success rate of bile duct cannulation in the patients whounderwent ERCP with the single‑bending duodenoscope (TJF‑260V)was higher in those without gastrectomy(89 %)than in those with a Billroth I gastrectomy and a multi‑bending duodenoscope might be beneﬁcial forbile duct cannulation in patients with a Billroth I gastrectomy. Shinshu Med J 63 : 385 ―389, 2015
(Received for publication June 18, 2015;accepted in revised form July 23, 2015)
Key words:ERCP, multi‑bending duodenoscope, Billroth I gastrectomy

Introduction
Endoscopic retrograde cholangiopancreatography
Corresponding author:Takeji Umemura
Department of M edicine, Shinshu University School ofMedicine, 3‑1‑1 Asahi, M atsumoto, Nagano 390‑8621,(ERCP)is a medical procedure that is essential forthe diagnosis and treatment of hepatobiliary andJapanpancreatic diseases. One of the key points for theE‑mail:tumemura＠shinshu‑u.ac.jp

eﬀective performance of ERCP is smooth bile duct

No. 6, 2015385

Arakura.Ito.Tanaka et al.

Fig. 1

A : Bile duct cannulation in a patient without gastrectomy, using a single‑bending
duodenoscope.The direction ofthe catheter(dashed‑line arrow)was adjusted to the bile duct,
and the distance between the head of the duodenoscope and the papilla of Vater (✿) wasappropriate. B : Bile duct cannulation in a patient with a Billroth l gastrectomy, using asingle‑bending duodenoscope.The direction of the catheter was not adjusted to the bile duct,
and the distance (✿) was too close. C :Bile duct cannulation in a patient with a Billroth lgastrectomy,using a multi‑bending duodenoscope.The direction ofthe catheter was adjusted
to the bile duct,and the distance (✿)was appropriate by bending the second‑bending portionof the duodenoscope.Closed arrowheads indicate the conventional bending portion.The openarrowhead indicates the second‑bending portion of the multi‑bending duodenoscope.

cannulation, which has a success rate of 85‑95%

in patients with a Billroth I gastrectomy andeven among well‑trained endoscopists . Importantcompared it to the rate in patients without a gas-factors for successful bile duct cannulation are thetrectomy. We also conducted a preliminary test ofdirection of the catheter in relation to the targetingthe performance of a multi‑bending duodenoscopeof the bile duct and the distance from the duodenos-

in patients whose bile duct cannulation was notcope to the papilla of Vater. A single‑bending

successful with a conventional endoscope.

duodenoscope, i.e., a conventional duodenoscope, isdesigned to keep the appropriate direction of thePatients and M ethods

catheter and head position easily at bile duct can-A total of 620 patients who underwent diagnostic

nulation in patients without a gastrectomy (Fig.

or therapeutic ERCP with a conventional single‑1A). Because the direction of the catheter becomes

bended duodenoscope at our endoscopic center

inappropriate and the distance to the papilla ofbetween January 2010 and December 2014 were

Vater becomes too close in patients with a Billroth

enrolled. Of those, 560 did not have a history ofI gastrectomy when using a conventional duodenos-gastrectomy,and the remaining 60 had undergone acope (Fig. 1B), endoscopists ﬁnd the cannulation

Billroth I gastrectomy. All patients had native

rather diﬃcult.So a multi‑bending duodenoscope ispapilla of Vater of the duodenum.The backgrounds

designed to more easily adjust the direction of theof the patients are compared in Table 1.

catheter and adjust the distance in patients with aThree patients without gastrectomy and three

Billroth I gastrectomy with the use of both thepatients with a Billroth I gastrectomy whose bile

original‑ and second‑bending portions (Fig. 1C).

duct cannulation was unsuccessful by conventional

Taking these conditions into consideration, weendoscopy underwent a retry of the cannulation

analyzed the success rate at our endoscopic centerwith the use of a multi‑bending duodenoscope.

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A multi‑bending duodenoscope
Table 1

Clinical background and success rate of bile duct cannulation using a single‑bending duodenoscope
between patients without gastrectomy and those with a Billroth l gastrectomy
Patients withoutgastrectomy

Patients with a Billroth I
gastrectomy

p‑value

No. of patients

560

60

Age (years)a
M ale/female (%)b72 (36‑98)
268/292 (48%/52%)

76 (68‑90)
22/38 (37%/63%)

0.082
0.099

210 (38%)

20 (33%)0.576

Bile duct stone
Others (AIP, papillitis et al.)

265 (47%)
85 (15%)31 (52%)9 (15%)

0.587
0.971

Success rate of biliary cannulationb
Post‑ERCP pancreatitisb

496 (89 %)
42 (8%)

51 (85%)5 (8%)

0.665
0.817

Indications of ERCP :b
M alignant biliary strictureaData are median (range). bData are expressed as a positive number (%). AIP :autoimmune pancreatitis.

Table 2Clinical background and success rate of bile duct cannulation using a multi‑bending duodenoscope(TJF‑Y0022)

No. of patientsAge (year)a
M ale/female (%)b
Indications of ERCP :b
M alignant biliary stricture
Bile duct stone
Others (AIP, papillitis, et al.)Success rate of biliary cannulationbPost‑ERCP pancreatitisb

Naive patients forbile duct cannulation

Patients whose bile duct cannulation was
unsuccessful with single‑bending duodenoscope

Without Gastrectomy

Without Gastrectomy

With Billroth I
gastrectomy

2076 (52‑92)
10/10 (50%/50%)

382 (80‑86)
1/2 (33%/67%)

381 (62‑90)
1/2 (33%/67%)

6 (30%)
11 (55%)
3 (15%)
19 (95%)
2 (10%)

1 (33%)

2 (67%)

2 (67%)
0 (0%)
0 (0%)
0 (0%)

1 (33%)
0 (0%)
3 (100%)0 (0%)aData are median (range). bData are expressed as a positive number (%). AIP :autoimmune pancreatitis.

ERCP using a multi‑bending duodenoscope was also

experienced endoscopist (N.A.)who had previously

performed in 20 patients without gastrectomy.The

performed over 1,000 ERCP procedures.The ERCP

clinical backgrounds of these patients are compared

procedure in patients with either of the following

in Table 2.All 26 of the patients who were examined

conditions were considered failures in the present

by multi‑bending duodenoscope had native papilla.

study:(1)the procedure required more than 15 min

All duodenoscopes used in the present study areof examination time,or(2)wire‑guided cannulation,

manufactured by Olympus M edical Systems

pancreatic guide‑wire placement, or precutting of(Tokyo). As shown in Figure 1, the multi‑bending

the papilla of Vater was required for the cannula-duodenoscope (TJF‑Y0022), which has a secondtion.

bending portion near the ordinary bending portion,
was modiﬁed from a commercially available single‑
bending duodenoscope (TJF‑260V).
All procedures were performed by one highly
No. 6, 2015

Results
The success rate of bile duct cannulation in thepatients who underwent ERCP with the single‑bend387

Arakura.Ito.Tanaka et al.

ing duodenoscope was higher in those without gas-a single‑bending duodenoscope.Imazu et al.report-trectomy (89 %) than in those with a Billroth I

ed two similar cases in which a multi‑bending

gastrectomy (85%) by 4%, but the diﬀerence wasduodenoscope was used (a diﬀerent type from ours),

not signiﬁcant.There were no signiﬁcant diﬀerences

further indicating the beneﬁt .Even if it exists,thein the clinical backgrounds or in the incidence of

beneﬁcial eﬀect of a multi‑bending duodenoscope

post‑ERCP pancreatitis between the two groups.

for bile duct cannulation in patients without aBile duct cannulation was successful with thegastrectomy seems minimal, because the success

multi‑bending duodenoscope in all three of therate of bile duct cannulation was similar between

patients with a Billroth I gastrectomy whose can-the present examinations using single‑ and multi‑

nulation was unsuccessful by conventional endos-

bending duodenoscopes, and because the cannula-copy. In contrast, the cannulation was not success-tion was unsuccessful in the three patients without

ful in all three of the patients without gastrectomy

gastrectomy in whom it was unsuccessful by single‑

whose cannulation was similarly unsuccessful. The

bending duodenoscopy. The safety of the multi‑

success rate in the 20 patients without gastrectomy

bending duodenoscope was similar to that of the

who were examined using the multi‑bending

single‑bending duodenoscope in terms of the inci-

duodenoscope was 95%,and this rate did not diﬀer

dence of post‑ERCP pancreatitis.This is the second

signiﬁcantly from that in the 560 patients without

beneﬁt of multi‑bending duodenoscope, because

gastrectomy who were examined with the single‑

other techniques that are known to help successful

bending duodenoscope(89 %).The incidenceofpost‑

cannulation, i.e. wire‑guided cannulation, pancre-

ERCP pancreatitis was similar between the patients

atic guide‑wire placement, and precutting of thefor whom the single‑ (7.6%, 47/620) and multi‑

papilla of Vater,are also known as risk factors forbending (7.7%, 2/26)duodenoscopes were used.

post‑ERCP pancreatitis.

Our preliminary data suggest that a multi‑bend-Discussion

ing duodenoscope might be beneﬁcial for bile duct

In this patient series,the success rate of bile ductcannulation in patients with a Billroth I gas-cannulation in the patients who were examined bya

trectomy. However, further studies are required tosingle‑bending duodenoscope was somewhat higher

verify our ﬁndings, as the number of patients anal-(by 4%) in those without a gastrectomy than inyzed using a multi‑bending duodenoscope wasthose with a Billroth I gastrectomy.We suspect thatsmall.

the diﬀerence in success rates was minimized

Conﬂict of Interest

because all of the procedures were performed by awell‑trained endoscopist.

The authors were provided with the prototype

Here, the beneﬁt of the multi‑bending duodenos-

multi‑bending duodenoscope by Olympus M edical

cope was suggested for bile duct cannulation inSystems Corp. (Tokyo) free of charge. The com-patients with a Billroth I gastrectomy because thepany had no role in the design,practice or analysis

cannulation was successful in all three patientsof this study.

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