Background

ERCP, especially therapeutic, is difficult in patients with Billroth II surgical reconstruction and is associated with a higher rate of complications. This has led to controversy on the choice between a forward-viewing and side-viewing endoscope for performing the procedure. A previous case series from Asia reported a high rate of success with a cap-fitted ERCP technique. To our knowledge, the utility of cap-assisted ERCP with a forward-viewing gastroscope when other techniques fail has not been reported. We describe and demonstrate a novel rescue approach using a cap-fitted, forward-viewing gastroscope in patients with Billroth II anatomy, when attempts with duodenoscopes, pediatric colonoscopes, and gastroscopes previously failed.

Methods

Retrospective case series. Inclusion criteria were: (a) documented Billroth II anatomy; and (b) use of cap-assisted ERCP as a rescue intervention on the first endoscopic encounter after failed attempts to perform ERCP with a duodenoscope. Patients were excluded if they successfully underwent ERCP with a duodenoscope. One advanced endoscopist and one advanced endoscopy fellow performed all but one of the procedures.

Results

Five cap-assisted ERCP procedures were performed in three patients with Billroth II anatomy. A wide variety of diagnostic and therapeutic endoscopic maneuvers were technically feasible and successful, including the endoscopic treatment of an afferent limb perforation caused by a duodenoscope.

Conclusions

Cap-assisted ERCP is a novel and underutilized technique that adds to the armamentarium of experienced therapeutic endoscopists. This approach may help ensure a successful endoscopic outcome and spare patients with Billroth II anatomy a percutaneous or surgical approach when ERCP with a duodenoscope, pediatric colonoscope or non-cap-fitted gastroscope fails.