T-tube assisted, non-endoscopic method for endobiliary drainage in a patient with Billroth II gastrectomy

Introduction: Several studies has shown that the rate to gain access to the main duodenal papilla and perform therapeutic ERCP in patients with previous Billroth II gastrectomy is only 60–70%. However, recent studies have reported better results using double balloon enteroscope, but its widespread use is limited. Now, we report a simple, less invasive and readily available method for treatment of extra hepatic biliary obstruction in a patient with previous Billroth II gastrectomy. Case report: The 90 year old male patient who suffered from number of chronic diseases presented with acute cholangitis caused by multiple CBD stones. We attempted ERCP several times by using either side viewing duodenoscope and/or gastroscope, but the intubation of the afferent limb failed. Eventually, open cholecystectomy, choledochotomy and T-tube drainage were carried out. T-tube cholangiogram performed post-operatively raised the suspicion of a retained stone of 5mm in size at the suprapapillary region of the CBD. Attempts to perform ERCP failed again. Ultimately, we introduced a standard papillotome loaded with a 0.036-inch J-tipped Teflon coated guide wire through the external opening of the T-tube. After having been reached the intracholedochal part of the tube, the tip of papillotome was maneuvered into the downward opening of the intracholedochal T-tube. The guide wire was passed through the descending limb of the tube into the distal part of the common bile duct and into the duodenum. Finally, a plastic stent of 7 F in diameter and 92mm in length was placed transpapillary through the guide wire using a 7 F pusher catheter. Following the procedure, a serial T-tube cholangiogram evidenced good contrast flow through the stent. The tube was removed 2 days later and the patient had a 6 months uneventful follow up. Conclusion: This simple, minimal invasive and not expensive method may be valuable in patients with Billroth II anatomy and previous T-tube placement who need endobiliary drainage.