endoscopic treatment of advanced biliary disorders and their complications following surgical procedures is often difficult especially after billroth ii gastric resection . in such cases , endoscopic access to the papilla and neopapilla thus , percutaneous cholangiodrainage or re - operation is therefore indicated when endoscopic access to the papilla failed . but both of those methods are much more invasive and more likely to be followed by complications than use of a purely endoscopic approach . the present case report describes endoscopic access to the papilla with both push enteroscopy and double - balloon enteroscopy ( dbe , push - and - pull enteroscopy ) in a female patient after billroth ii resection with bile leakage following cholecystectomy . successful closure of the bile duct fistula could be achieved via an unusual abdominal - biliary - jejunal cannulation way after several attempts of modern enteroscopy and in this way re - operation was avoided . modern enteroscopy by experienced investigators using push - and - pull enteroscopes can provide access to the papilla even in complex postoperative anatomic rearrangements . push - and - pull enteroscopes offer a further option for successful cannulation of the papilla and therapeutic interventions via additional stabilization with balloons and the modern enteroscopic approach by push - and - pull enteroscopy appears to provide more patient comfort , requires less analgo - sedation and examination time and in cases with intra - abdominal drainage this external access may be used as an additional aid for exploration and intervention in complex individual cases with extremely difficult treatable bile duct injuries . endoscopic treatment of advanced biliary disorders and their complications ( e.g. benign , malignant strictures , bile duct trauma , bile duct leakage etc ) following surgical procedures is often difficult after billroth ii gastric resection , whipple s operation or extensive resection of the small intestine . in such cases , endoscopic access to the papilla and neopapilla is often low ( 525% ) , and access to the choledocho- or hepaticojejunostomy is often hampered by jejunal loops of different lengths , awkwardly positioned braun s anastomoses or even by postoperative alterations ( e.g. adhesions ) [ 15 ] . thus , percutaneous cholangiodrainage ( ptcd ) or re - operation is therefore indicated when endoscopic access to the papilla failed . but ptcd is regarded as much more invasive and more likely to be followed by complications than use of a purely endoscopic approach , especially in persons who have undergone billroth ii resection with a long afferent loop or a roux - en - y construction . the present case report describes endoscopic access to the papilla with both push enteroscopy and double - balloon enteroscopy ( dbe , push - and - pull enteroscopy ) in a female patient after billroth ii resection with bile leakage following cholecystectomy . successful closure of the bile duct fistula could technically only be achieved via an unusual abdominal - biliary - jejunal cannulation way after several attempts of modern enteroscopy and in this way re - operation was avoided . a 79-year - old female patient was transferred from the surgical unit of an external hospital to the department of medicine 1 of the university erlangen because of an ouvert persisting bile duct leakage after open cholecystectomy . cholecystectomy was required to treat acute cholecystitis with choledocholithiasis , since endoscopic stone removal by gastroscope and side - viewing duodenoscope ( ercp ) failed due to lack of access to the papilla after bilroth ii resection . at admission , the patient presented with an intraabdominal drain secreting approximately 500 ml of bile per day , both into the abdominal cavity and externally via an easy - flow drainage . at the time of admission the patient was awake and her cardiovascular system stable , but she presented with dementia . her current schedule of medication was metoprolol 47.5 mg / d and thiamazol 10 mg / d . the physical examination revealed poor general health , a slightly adipose nutritional status ; blood pressure was 110/80 mmhg with 100 heartbeats / min , body temperature 37.6c . there was a vesicular respiratory sound and a respiration rate of 16/min . a well - healed median laparotomy scar was found after open cholecystectomy and normal peristaltic sounds in all quadrants . at the time of admission the woman had a bile collection bag due to persisting leakage in the right upper abdomen ; an intra - abdominal drainage tube was still in place . laboratory tests showed the following values : crp slightly elevated at 18 mg / l ( < 5 mg / l ) , got elevated at 77 u / l ( < 31 u / l ) , gpt 65 u / l ( < 34 u / l ) , cholestasis with gamma - gt 580 u / l ( < 38 u / l ) , alkaline phosphatase 674 u / l ( 53141 u / l ) , bilirubin 1.5 mg / dl ( < 1.0 mg / dl , of which 0.7 mg / dl was direct bilirubin and 0.8 mg / dl indirect bilirubin ) . billroth ii gastric resection had been carried out in 1982 because of peptic ulcer disease . access to the braun s anastomosis was achieved 20 cm distally from gastro - jejunal anastomosis ( 58 cm ) by means of push enteroscopy ( sif q140 , olympus , japan ) and the afferent loop with a further length of 42 cm could be traversed only by enteroscopy . at the first examination , the papilla was found at the end of the afferent loop at 120 cm depth , approximately 1.5 cm away from the unattached , closed end ; however , the papilla could only be viewed tangentially . following the difficult adjustment of focus on the papilla with a sif q140 push - enteroscope ( olympus , japan ) , contrast medium was applied and showed an unobstructed bile duct system ; however , the proximal common bile duct was clearly pulled out of shape in a v - shaped curve to the left ( figures 1 and 2 for a postoperative view ) . contrast medium was clearly seen to emerge from the v - shaped bend of the bile duct approximately 3 cm proximally from the papilla , with rapid formation of a 2.41.0 cm large depot of contrast medium ( figure 1 ) nearby the surgically placed abdominal drainage . the surgically emplaced robinson drainage tube laid since the time of cholecystectomy ( postoperative day 68 ) . although the bile duct leakage could endoscopically be illustrated during pro - grade ercp , it remained impossible to selectively cannulate the distal bile duct using the push enteroscope ( sif q140 , olympus , japan ) , since the bile duct tended to bend sharply at an angle of 90 along the course of the distorted bile duct s curve ( figures 1 , 2 ) . at the end of this unsuccessful examination , the afferent loop was marked with sterile ink ( gi - supply co. , sold by mandel & rupp co. , erkrath , germany ) . a second attempt using a sif q140 push - enteroscope ( olympus , japan ) and a lateral - viewing enteroscope ( tjf 160 , olympus , japan ) failed and thus , a third examination was performed by push - and - pull - enteroscopy ( dbe based ercp ) , since a balloon - assisted course of action held out the promise of greater stability for positioning the endoscope in relation to the papilla . although it proved possible to cannulate the biliary system now for the first time , the insertion of a more rigid endoprosthesis failed at this moment . at a second dbe based prograde , technically very demanding ercp ( en-450t5 , fujinon , japan ) , it appeared initially again impossible to introduce more rigid instruments into the cranial parts of the bile duct due to postoperatively altered anatomy . thus , in order to avoid an open re - operation , an unusual abdominal - biliary cannulation way was tried during enteroscopy and fluoroscopy by advancing a wire into the bile duct via the abdominal drain which was already in place ( figures 2 , 3 ) . thereupon it was found that the position of the abdominal drain was apparently intraductal , since the passageway was immediately explorable with a flexibe j - terumo guidewire ( figure 3 ) . the abdominal drain was therefore probed percutaneously with the flexible terumo wire , making it possible to reach the distal common bile duct and then to advance the terumo wire into the intestinal passageway . this guidewire was then grasped with a biopsy forceps and pulled to the outside ( figure 3 ) . while the terumo guidewire was held in place at the abdominal drain , the ercp catheter was introduced endoscopically over the guidewire straight into the distal bile duct . even then , however , it proved impossible to reach the cranial bile duct due to the disadvantageous vertical position in relation to the bile duct wall . a maxforce balloon ( 4 mm ) was then introduced percutaneously via the abdominal drain , advanced to the v - shaped pucker of the proximal common bile duct , and successfully plugged the bile duct leak ( fig . 4 ) . now at last , it was possible to advance the ercp catheter straight ahead and probe the cranial bile duct system , since the wire , when advanced in a straight line ,  bounced  off the balloon which had plugged the leakage , and moved toward the hilus ( figures 4 , 5 ) . finally , the bile duct system cranially to the hilus could be selectively reached , allowing insertion of a rigid blackwire guidewire for stable position . implantation of a 7 fr double - pigtail prosthesis in segment ii ( figure 5 ) for decompression of the biliary tract was achieved by using a 5 fr nasobiliary probe as pusher . interestingly , three days after implantation of the 7 fr double - pigtail prosthesis , secretion of bile from the abdominal drain had already come to a full stop . antibiotic therapy was discontinued after removal of the abdominal drain prior to the patient s release from our hospital . bile duct injury has been reported to be less common after open cholecystectomy ( 0.20.5% ) than after laparoscopic cholecystectomy ( 02.7% ) . small bile leaks are more commonly found after laparoscopic cholecystectomy ( 1015% ) and are in most cases clinically asymptomatic . large , clinically relevant leaks manifest as biliary fistulas , biliary ascites , peritonitis etc . and are potentially fatal if left untreated . although endoscopic treatment of bile duct leakage by performing papillotomy , insertion of nasobiliary probe or stent placement is deemed as first line therapy of choice , these interventions and the endoscopic approach may be technically very difficult or impossible in postsurgical patients with altered abdominal anatomy as described here in a female patient with injured bile duct and status after billroth ii resection with roux - en - y loop . although conventional endoscopy using gastroscope and side - viewing duodenoscope was repeatedly unsuccessful , enteroscopy with both a push enteroscope and a push - and - pull enteroscope was able to gain access to the papilla at 120 cm insertion depth , to illustrate the biliary tree and to recognize exactly the position of the bile duct trauma . in order to avoid open re - operation , several enteroscopic attempts had to be undertaken until a successful complex enteroscopic and radiological intervention using the intraabdominal drainage for an unusual bile duct cannulation could be performed . after cannulation of the injured bile duct via the abdominal drainage to the bile duct leakage and then to the afferent jejunal loop by a flexible guidewire , intermittent closure of the bile duct leakage was then required by a 4 mm max force balloon to achieve selective cannulation of the proximal and intrahepatic ducts . a permanent closure of this technically very demanding , v - shaped bile duct injury during prograde enteroscopy based erc was finally achieved after insertion of a 7fr double - pigtail endoprosthesis . as to our knowledge , the above mentioned unusual cannulation way via the abdominal drainage to the bile leakage and then through the papilla to the jejunum with intermittent closure of the bile leakage by a balloon has not yet been described in the literature for treatment of bile duct injuries up to now . interestingly , push - and - pull enteroscopy provided a much better and more stable position at the papilla due to use of a balloon on the overtube and the enteroscope tip than push enteroscopy . by inflating the balloon on the tip of the enteroscope the very tangentially position of the enteroscope in front of the papilla could sometimes be compensated , which allowed first successful guidewire cannulation . but apart from the postoperative endoscopic route to the papilla , the situation was much more complicated , however , by the v - shaped angle of the bile duct , the size of the leakage and the extremely unfavorable postoperative anatomy of the biliary system , requiring further innovative interventional steps like usage of the abdominal drainage as cannulation way , extraction of the guidewire out of the enteroscope , intermittent closure of the bile leakage from the external access by an appropriate high - pressure balloon allowing finally the permanent decompression of the biliary system with an effective endoprosthesis therapy . this case report illustrates the following points : 1 ) modern enteroscopy by experienced investigators using push - and - pull enteroscopes can provide access to the papilla even in complex postoperative anatomic rearrangements . 2 ) push - and - pull enteroscopes offer a further option for successful cannulation of the papilla and therapeutic interventions via additional stabilization with balloons and 3 ) the modern enteroscopic approach by push - and - pull enteroscopy appears to provide more patient comfort , requires less analgo - sedation and examination time and 4 ) in cases with intra - abdominal drainage this external access may be used as an additional aid for exploration and intervention in complex individual cases with extremely difficult treatable bile duct injuries . admission of such patients to experienced endoscopic centers for checking , examination and trying of conservative interventional endoscopic- or enteroscopic - radiological therapy is thus warranted before performing bile duct re - operation in such patients . concerning the proceeds and cost situation of the endoscopic therapy the effective amount for this therapy was 5287,91  according to the german accounting system ( drg ; primary / leading diagnosis : h41a ) . the comparable surgical therapy ( open revision of the biliary tract and surgical placement of a stent ) would have resulted in costs of 7165,57  ( primary / leading diagnosis : h05z ) . all in all , endoscopic therapy represents a more conservative and more cost - effective method to treat complex postoperative bile duct leakage , most notably by use of modern enteroscopy in experienced centers .
summarybackgroundendoscopic treatment of advanced biliary disorders and their complications following surgical procedures is often difficult especially after billroth ii gastric resection . in such cases , endoscopic access to the papilla and neopapilla 
 is often low , and access to the choledocho- or hepaticojejunostomy is often difficult.thus , percutaneous cholangiodrainage or re - operation is therefore indicated when endoscopic access to the papilla failed . but both of those methods are much more invasive and more likely to be followed by complications than use of a purely endoscopic approach.case reportthe present case report describes endoscopic access to the papilla with both push enteroscopy and double - balloon enteroscopy ( dbe , push - and - pull enteroscopy ) in a female patient after billroth ii resection with bile leakage following cholecystectomy.successful closure of the bile duct fistula could be achieved via an unusual abdominal - biliary - jejunal cannulation way after several attempts of modern enteroscopy and in this way re - operation was avoided.conclusionsmodern enteroscopy by experienced investigators using push - and - pull enteroscopes can provide access to the papilla even in complex postoperative anatomic rearrangements.push-and-pull enteroscopes offer a further option for successful cannulation of the papilla and therapeutic interventions via additional stabilization with balloons and the modern enteroscopic approach by push - and - pull enteroscopy appears to provide more patient comfort , requires less analgo - sedation and examination time and in cases with intra - abdominal drainage this external access may be used as an additional aid for exploration and intervention in complex individual cases with extremely difficult treatable bile duct injuries .