title: A randomized trial of endoscopic balloon dilation and endoscopic sphincterotomy for removal of bile duct stones in patients with a prior Billroth II gastrectomy.
abstract: BACKGROUND
  A prior Billroth II gastrectomy renders endoscopic sphincterotomy (EST) more difficult in patients with bile duct stones. Endoscopic balloon dilation (EBD) is a relatively easy procedure that potentially reduces the risk of bleeding and perforation.
  
  
  METHODS
  Thirty-four patients with bile duct stones and a previous Billroth II gastrectomy were randomized to EST or EBD. Complications were graded in a blinded fashion. Results were compared with those for a group of 180 patients with normal anatomy from a previously reported randomized trial of EBD versus EST.
  
  
  RESULTS
  All stones were removed in 1 endoscopic retrograde cholangiopancreatography in 14 of 16 patients who underwent EBD versus 14 of 18 who had EST (p = 1.00). Mechanical lithotripsy was used in 3 EBD procedures versus 4 EST procedures (p = 1.00). Early complications occurred in 3 patients who had EBD versus 7 who underwent EST (p = 0.27). Three patients had bleeding after EST; 1 patient had mild pancreatitis after EBD. The median time required for stone removal was 30 minutes in both groups. Compared with patients with a normal anatomy, patients with a previous Billroth II gastrectomy had a significantly increased risk of bleeding after EST (17% vs. 2%, relative risk = 7.25, p < 0.05).
  
  
  CONCLUSIONS
  A prior Billroth II gastrectomy renders EST more difficult and increases the risk of a complication. EBD in these patients is easy to perform and is not associated with an increased need for mechanical lithotripsy or a longer procedure time. The risk of bleeding is virtually absent after EBD and the risk of pancreatitis after EBD seems not significantly increased in these patients.
authors.affiliation: Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: J J
authors.initials: JJ
authors.lastname: Bergman
authors.forename: A M
authors.initials: AM
authors.lastname: van Berkel
authors.forename: M J
authors.initials: MJ
authors.lastname: Bruno
authors.forename: P
authors.initials: P
authors.lastname: Fockens
authors.forename: E A
authors.initials: EA
authors.lastname: Rauws
authors.forename: J G
authors.initials: JG
authors.lastname: Tijssen
authors.forename: G N
authors.initials: GN
authors.lastname: Tytgat
authors.forename: K
authors.initials: K
authors.lastname: Huibregtse
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001649:Bile Duct Diseases / Q000628:therapy; D002404:Catheterization / Q000009:adverse effects; D002769:Cholelithiasis / Q000628:therapy*; D005260:Female; D005743:Gastrectomy / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011183:Postoperative Complications / Q000628:therapy*; D012074:Remission Induction; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects