Tips for Successful Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II Gastrectomy

success rate for cannulating the desired duct in surgically altered anatomy status, such as Billroth II gastrectomy has been just above 50%; while the overall success rate for selective cannulation has been about 90% in normal anatomy. 1 In addition to this low success rate, endoscopic retrograde ch-olangiopancreatography (ERCP) procedure has been known as a challenging way even for experts in patients who had previously undergone Billroth II gastrectomy due to the possibility of small bowel perforation by endoscope. 2 Two problems are inherent during ERCP in patients with previous Billroth II gastrectomy. First, the afferent loop intubation can be difficult because of the sharp angulation of the anastomosis site or a long afferent loop. The second problem is that the cannulation has to be done in an opposite direction. Many manipulations have been attempted to improve the success rate of ERCP procedure in Billroth II gastrectomy. 3 The special manipulations, such as tube insertion, using pediatric colonoscope, wire guided intubation, and large balloon dila-tion, have been suggested to help reach the papilla through long afferent loop. Using large channel duodenoscope which accepts variable accessories with an elevator was previously recommended in Billroth II ERCP. However, this duodenoscope is hard to assess afferent loop and pass the Treiz ligament. Above all things, the risk of small bowel perforation is relatively high while using duodenoscope. It was reported that single-or double-balloon enteroscope enable successful ERCP in patients with an altered anatomy. However, there were still limitations on using ERCP accessory due to long working length and small size of channel. Recently, there were some reports that the high rate of successful ERCP was achieved by using forward viewing endoscope in patients with Billorth II gastrec-tomy. Byun et al. 6 reported Billorth II ERCP by using regular gas-troscope in this issue of Clinical Endoscopy. The overall success rate of reaching the papilla was 42 out of 46 (91%) and selective cannulation of the bile duct was successful in all patients (42 out of 42 patients, 100%) after the approach of papilla. No serious complications were encountered, except for one case of small perforation due to endoscopic sphincterotomy site injury. The authors announced that the intubation of the afferent loop using forward-viewing gastroscope was easy in most cases without time consuming. If the gastroscope reached the papilla, bile duct cannulation was not difficult because the en-doscope and the catheter were in line with …