IJGII Inernational Journal of Gastrointestinal Intervention

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Original Article

Int J Gastrointest Interv 2023; 12(3): 115-122

Published online July 31, 2023 https://doi.org/10.18528/ijgii230006

Copyright © International Journal of Gastrointestinal Intervention.

Endoscopic retrograde cholangiopancreatography in patients with pancreaticoduodenectomy with and without the use of a rigidizing overtube

Daniel J. Low , Abraham Yu, Cynthia Liu, Faisal Shaukat Ali, Ahmad Al Nakshabandi , Emmanuel Coronel , Phillip Ge , and Jeffrey H. Lee*

Department of Gastroenterology, Hepatology & Nutrition, MD Anderson Cancer Center, Houston, TX, USA

Correspondence to:*Department of Gastroenterology, Hepatology & Nutrition, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
E-mail address: jefflee@mdanderson.org (J.H. Lee).

Received: January 27, 2023; Revised: May 30, 2023; Accepted: May 30, 2023

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography (ERCP). While ERCP maintains a success rate of 90% to 95% in patients with native anatomy, the data are less robust for patients with post-pancreaticoduodenectomy (PD) anatomy. We conducted a retrospective analysis of the technical success (TS) and clinical success (CS) rates of ERCP in post-PD patients. In addition, we describe our experience using novel rigidizing overtubes to facilitate post-PD ERCP.
Methods: Patients with PD referred to our institution between 2006 and 2021 for ERCP were included. Major outcomes included the TS rate (successful biliary intervention) and the CS rate (improvement in patient symptomatology with or without normalization of bilirubin levels).
Results: In total, 47 patients underwent 102 ERCPs for biliary (n = 98) and pancreatic (n = 4) indications. The overall TS and CS rates were 82.4% and 75.5%, respectively. Rigidizing overtubes were utilized in 5 patients who underwent 11 ERCPs, with TS and CS rates of 90.9% and 90.9%, respectively. The overall adverse event rate was 4.9%, with no adverse events noted in cases with rigidizing overtubes.
Conclusion: Despite the challenges in ERCP in patients with surgically altered anatomy, this retrospective analysis demonstrates a moderately high TS rate with minimal adverse events. A rigidizing overtube may be utilized to improve TS and CS in patients with post-surgical anatomy.

Keywords: Carcinoma, pancreatic ductal, Cholangiopancreatography, endoscopic retrograde, Endoscopy, gastrointestinal, Pancreatic neoplasms, Pancreaticoduodenectomy

Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP). Patients are frequently encountered in clinical practice with a history of the following surgical procedures that affect ERCP success: Billroth II, Roux-en-Y gastric bypass, Roux-en-Y hepaticojejunostomy and pancreaticoduodenectomy (PD; Whipple procedure). With respect to PD, immense surgical improvements have led to significantly decreased mortality. However, postoperative morbidity is still present in many cases, including complications such as biliary stricture, pancreaticocutaneous fistula, and delayed gastric emptying.13 As the Whipple procedure has become more routine in the management of benign and malignant conditions, the need for endoscopic therapeutic interventions has grown in tandem.

Patients with post-PD anatomy can present with pancreaticobiliary symptoms stemming from changes in their anatomy, in addition to common pathologies including choledocholithiasis. Obstructive jaundice can occur from recurrent disease or surgical bilioenteric anastomotic strictures. Prior studies have demonstrated that 2.6% of patients develop bilioenteric strictures within 13 months, and 8.2% in 5 years.3,4 Likewise, recurrent pancreatitis or abdominal pain can occur from a stricture of the pancreatic duct or pancreaticojejunal anastomosis. However, endoscopic management and evaluation with ERCP can be challenging. The difficulties in performing endoscopy are not only related to navigating through altered anatomy, but also to the lack of devices specifically designed for post-surgical anatomy.5,6 Several techniques have been attempted to improve the success of pancreaticobiliary interventions. Most notably, single-balloon enteroscopy, double-balloon enteroscopy, and rotational overtubes have been utilized to improve post-Whipple ERCP technical success.711 In addition, endoscopic ultrasound (EUS)-guided therapies including EUS-pancreatic duct drainage (EUS-PDD) and EUS-enteroenterostomy have been described as possible solutions to assist in ERCP.1216

Although ERCP maintains a success rate of 90% to 95% in patients with native gastric and pancreaticoduodenal anatomy, the data are less robust in patients with post-PD anatomy.17,18 Moreover, the use of a rigidizing overtube in ERCP has not been well described as an adjunctive device in post-surgical anatomy.19 In this study, a retrospective analysis was conducted to evaluate the technical success rate, clinical success rate, reasons for failure, and adverse events in post-PD patients undergoing ERCP with and without a rigidizing overtube.

This was a retrospective study performed at MD Anderson Cancer Center between 2006 and 2021. The protocol (RCR05-0672) was approved by the institutional review board.

Patient and procedural characteristics

Patients who had undergone PD (Whipple’s procedure) and required ERCP were included. Electronic medical records were used to capture pertinent demographic information, oncologic history, indications for PD, biochemical data, and follow-up information. ERCP procedural reports were analyzed for the indication, selection of the endoscope used, primary anastomosis evaluated, stricture location, treatment for the stricture, and stent characteristics. Each procedure was included as a separate entry for patients who received multiple ERCPs. A Pathfinder (Neptune Medical) rigidizing overtube was used as an adjunctive device in a subset of cases.


The major outcomes were the technical and clinical success rates. The technical success rate was defined as the ability to perform an intended therapeutic intervention, including the evaluation of a stricture, stent placement, and stent removal. The clinical success rate was defined as a documented improvement of bilirubin to normal or 50% of the peak value within 4 weeks. The clinical success rate was not calculated for pancreatic indications. The additional outcomes evaluated included the reasons for technical failure and an analysis of the adverse events.


Descriptive statistics were used to characterize the demographic and clinical characteristics of the study population. The statistical analysis was performed using Stata/SE version 16.0 statistical software (Stata Corp.).

Patient characteristics

In total, 102 ERCPs were performed in 47 patients with prior PD. Within this sample, there were 31 male (66.0%) and 16 female (34.0%) patients. The patients’ mean age was 61.5 years of age. The indication for PD in the majority of patients was pancreatic adenocarcinoma (n = 26; 55.3%). A comprehensive list of patient characteristics, including the primary malignancy and neoadjuvant therapy, can be found in Table 1.

Table 1 . Patient Characteristics.

Age (yr)61.5 ± 11.6
Sample size (n)47
Male31 (66.0)
Female16 (34.0)
Primary malignancy
Pancreatic adenocarcinoma26 (55.3)
Pancreatic neuroendocrine tumor5 (10.6)
Ampullary adenocarcinoma4 (8.5)
Ampullary adenoma1 (2.1)
Ampullary neuroendocrine tumor1 (2.1)
Duodenal adenocarcinoma2 (4.3)
Duodenal adenoma with high grade dysplasia1 (2.1)
Duodenal neuroendocrine tumor1 (2.1)
Intraductal papillary mucinous neoplasm3 (6.4)
Mucinous cystic neoplasm1 (2.1)
Metastatic renal cell carcinoma1 (2.1)
Cholangiocarcinoma1 (2.1)
Neoadjuvant therapy
Chemoradiation11 (23.4)
Chemotherapy9 (19.1)
Radiation2 (4.3)
No neoadjuvant therapy25 (53.2)

Procedure details

Among the 102 procedures, there were 98 biliary and 4 pancreatic indications for ERCP, the majority of which included obstructive jaundice (n = 22; 21.6%), cholangitis (n = 35; 34.3%), and stent evaluation, including removal or exchange (n = 30, 29.4%). A complete list of procedural indications can be found in Table 2. Choledochojejunal or pancreaticojejunal anastomoses were identified in 90 procedures (89 choledochojejunal and 1 pancreaticojejunal). The anastomosis was reached mainly with a therapeutic upper endoscope (n = 31; 34.4%), adult colonoscope (n = 20; 22.2%), and pediatric colonoscope (n = 17; 18.9%). The anastomosis was reached using a duodenoscope (n = 1; 1.1%) and upper endoscope (n = 2; 2.2%) in a minority of patients. Of note, the endoscope used to reach the anastomosis was not specified in 19 (21.1%) procedures.

Table 2 . Procedure Characteristics.

n (%)
Total procedures (n)102
Biliary98 (96.1)
Obstructive jaundice22 (21.6)
Cholangitis35 (34.3)
Choledocholithiasis1 (1.0)
Ductal dilation4 (3.9)
Evaluation of stricture5 (4.9)
Stent evaluation30 (29.4)
Elevated liver enzymes1 (1.0)
Pancreatic4 (3.9)
Pancreatitis4 (3.9)
Endoscope used for successful interventions
Adult colonoscope20 (23.8)
Duodenoscope1 (1.2)
Pediatric colonoscope15 (17.9)
Therapeutic upper endoscope30 (35.7)
Upper endoscope2 (2.4)
Not specified16 (19.0)
Indicated cannulations101
Biliary97 (96.0)
Successful86 (88.7)
Unsuccessful11 (11.3)
Pancreatic4 (4.0)
Successful0 (0.0)
Unsuccessful4 (100.0)
Indicated cannulations (adjusted after anastomosis identification)89 (87.3)
Biliary88 (98.9)
Successful86 (97.7)
Unsuccessful2 (2.3)
Pancreatic1 (1.1)
Successful0 (0.0)
Unsuccessful1 (100.0)
Cholangiograms and pancreaticograms conducted90 (88.2)
Biliary89 (98.9)
Choledochojejunal stricture51 (57.3)
Common hepatic stricture2 (2.2)
Hilar stricture2 (2.2)
Intrahepatic stricture6 (6.7)
No stricture28 (31.5)
Pancreatic1 (1.1)
No stricture1 (100.0)
Stent characteristics55
Plastic49 (89.1)
Uncovered metal4 (7.3)
Covered metal2 (3.6)

Biliary (n = 97) or pancreatic (n = 4) duct cannulation was indicated in 101 procedures. One patient underwent ERCP and stent removal without the need for cannulation or additional biliary intervention. Successful cannulation occurred in 86 (88.7%) patients requiring biliary intervention, and 0 (0.0%) patients requiring pancreatic intervention. When the anastomosis of interest was identified, cannulation was successful in 86 (97.7%) patients requiring biliary interventions and 0 (0.0%) patients requiring pancreatic interventions.

Among all patients, 90 (88.2%) patients had cholangiograms (n = 89; 98.9%) or pancreaticograms (n = 1; 1.1%) conducted. In the patients with cholangiograms, most strictures were choledochojejunal in origin (n = 51; 57.3%). Conversely, 28 patients did not have strictures (31.5%). The other strictures identified on cholangiograms included intrahepatic (n = 6; 6.7%), hilar (n = 2; 2.2%), and common hepatic duct (n = 2; 2.2) strictures. The single pancreaticogram conducted showed no evidence of stricture or additional pathology. Among the patients requiring stent placement, 49 required plastic stent placement (n = 49; 89.1%). Two patients had fully covered metal stents deployed (3.6%), and four patients had uncovered metal stents inserted (7.3%). All patients who underwent uncovered stent deployment had choledochojejunal strictures. Of the patients receiving fully covered metal stent placement, one patient had a choledochojejunal stricture and the other did not have evidence of stricture. All other patients had plastic stents deployed regardless of stricture location (Table 3).

Table 3 . Stricture Types and Stents Utilized.

Stricture typePlasticCovered metalUncovered metal
Common hepatic200
No stricture610

Major outcomes

The technical success rate for ERCP in post-PD patients was 82.4% (84/102). Biliary procedures had a technical success rate of 84.7% (83/98), whereas pancreatic procedures had a technical success rate of 25.0% (1/4). The clinical success rate was 75.5% (74/98). Failure of biliary interventions mostly occurred secondary to the inability to reach or visualize the anastomosis (n = 10). Three additional procedures were unsuccessful given the degree of stricture at the level of the choledochojejunal anastomosis and the inability to pass instruments across the stricture. One of these procedures included an EUS-guided rendezvous procedure, in which the guidewire could not be passed antegrade across the stricture after obtaining biliary access. Moreover, two procedures were unsuccessful secondary to stent-related issues: one failure of stent deployment, and one in which there was no appropriate stent size available. With regard to pancreatic evaluation, technical success was achieved in one case for the evaluation of a suspected pancreaticojejunal stricture. The anastomosis was visualized, but the pancreatic duct could not be cannulated. However, a pancreaticogram was conducted and did not demonstrate any stricture or abnormality. All three unsuccessful cases were related to difficulty in identifying the pancreaticojejunal anastomosis and the inability to perform a pancreaticogram (Table 4).

Table 4 . Overall Technical and Clinical Success.

n (%)
Overall technical success
Biliary and pancreatic procedures102
Successful84 (82.4)
Unsuccessful18 (17.6)
Overall biliary technical success
Biliary procedures98
Successful83 (84.7)
Unsuccessful15 (15.3)
Overall pancreatic technical success
Pancreatic procedures4
Successful1 (25.0)
Unsuccessful3 (75.0)
Overall clinical success
Biliary procedures98
Successful74 (75.5)
Unsuccessful24 (24.5)
Pathfinder technical success
Pathfinder procedures11
Successful10 (90.9)
Unsuccessful1 (9.1)
Pathfinder clinical success
Pathfinder procedures11
Successful10 (90.9)
Unsuccessful1 (9.1)

Rigidizing overtubes

Pathfinder rigidizing overtubes were utilized in 11 ERCPs and 5 patients. The indications included stent evaluation, including removal, insertion, or exchange (n = 5; 45.5%), obstructive jaundice (n = 3; 27.3%), evaluation of stricture (n = 2; 18.2%) and cholangitis (n = 1; 9.1%). The choledochojejunal anastomosis was reached in all cases (n = 11; 100%). The endoscopes used with rigidizing overtubes included therapeutic endoscopes (n = 6; 54.5%) and adult colonoscopes (n = 3; 27.3%). The remaining endoscopes used with rigidizing overtubes were unspecified (n = 2; 18.2%). A cholangiogram was obtained in all cases. The majority of strictures were choledochojejunal in origin (n = 9; 81.8%). There was one additional intrahepatic stricture (n = 1; 9.1%). The last patient did not have a stricture identified on a cholangiogram. All stents deployed for intervention were plastic (n = 9; 100%) (Table 5). Technical success was achieved in 10 of 11 procedures (90.9%). The unsuccessful procedure (described above) was secondary to a severe choledochojejunal stricture, in which a guidewire could not be passed antegrade under an EUS-rendezvous approach. Clinical success was achieved in 10 of 11 procedures (90.9%).

Table 5 . Procedure Characteristics (Pathfinder).

n (%)
Total procedures11 (10.8)
Biliary11 (100.0)
Obstructive jaundice3 (27.3)
Cholangitis1 (9.1)
Choledocholithiasis0 (0.0)
Ductal dilation0 (0.0)
Evaluation of stricture2 (18.2)
Stent evaluation5 (45.5)
Elevated liver enzymes0 (0.0)
Endoscope used for procedure11
Adult colonoscope3 (27.3)
Duodenoscope0 (0.0)
Pediatric colonoscope0 (0.0)
Therapeutic upper endoscope6 (54.5)
Upper endoscope0 (0.0)
Not specified2 (18.2)
Indicated cannulations*11
Biliary11 (100.0)
Successful11 (100.0)
Unsuccessful0 (0.0)
Cholangiograms conducted11
Choledochojejunal stricture9 (81.8)
Common hepatic stricture0 (0.0)
Hilar stricture0 (0.0)
Intrahepatic stricture1 (9.1)
No stricture1 (9.1)
Stent characteristics9
Plastic9 (100.0)
Uncovered metal0 (0.0)
Covered metal0 (0.0)

Adverse events

There were 5 (4.9%) adverse events in the 102 procedures. There were three cases of fever, and one case of cholangitis, all of which resolved either with supportive care or antibiotics. One patient had post-procedure nausea and abdominal pain, which resolved with supportive management. No additional procedure-related adverse events occurred, including bleeding, perforation, pancreatitis, the need for surgical intervention, or death following ERCP. In addition, there were no procedure-related adverse events in patients in whom rigidizing overtubes were utilized.

A retrospective analysis of 47 patients undergoing 102 ERCPs post-PD demonstrated an overall technical success rate of 82.4% and clinical success rate of 75.5%. Rigidizing overtubes were utilized in a subgroup of patients with a technical success rate of 90.9% and clinical success rate of 90.9%. The overall adverse event rate was 4.9%, and most adverse events were mild (self-resolving fevers). Therefore, ERCP is a safe and effective therapeutic procedure in post-PD anatomy for biliary intervention. The use of a rigidizing overtube may enhance technical and clinical success in ERCP; however, additional studies need to be undertaken for further evaluation.

In a review of the literature, our biliary technical success rate was similar to that reported by Chahal et al.17 In comparison to the study of Chahal et al,17 in which most procedures were conducted with duodenoscopes, our procedures were conducted mainly with therapeutic upper endoscopes, adult colonoscopes, and pediatric colonoscopes with similar success. Chahal et al17 reported two adverse events: one medically managed retroperitoneal perforation and one self-resolving Mallory Weiss tear. The increased rate of perforation is a well-described adverse event of side-viewing endoscopes, and as such, the utilization of duodenoscopes was limited in our sample. Despite the use of forward-viewing endoscopes, similar technical success was achieved.

In our study, biliary cannulation was highly successful (97.7%) if the choledochojejunostomy was identified. Most failed biliary ERCPs were related to an inability to visualize or navigate the endoscope to the level of the anastomosis. Advancement of the endoscope to the choledochojejunostomy can be challenging. It requires accurate identification of the afferent limb and traversal to the anastomotic site. Post-PD anatomy encourages acute bowel angulation and loop formation, making it difficult to advance to the choledochojejunostomy site (Fig. 1, 2). Moreover, the limited visibility of a side-viewing scope, decreased flexibility, and larger caliber duodenoscope hinders the traversal of the endoscope to the anastomosis and heightens the risk for perforation. To mitigate some of the anatomic challenges of post-PD anatomy, a novel finding in this study related to the use of Pathfinder rigidizing overtubes in a subgroup of patients requiring ERCP. Rigidizing overtubes can dynamically rigidize and transform between a flexible and rigid state, which can straighten acute angulations, prevent loop formation, and stabilize endoscopes for therapeutic intervention (Fig. 35). Based on this limited sample, rigidizing overtubes can be a safe and effective adjunctive tool in reaching the choledochojejunostomy site and facilitating successful cannulation in patients with post-PD anatomy. Most studies have cited the successful use of rigidizing overtubes in difficult colonoscopies, but the literature has been sparse in demonstrating its use in ERCP, especially in patients with altered anatomy.19 Prior studies have demonstrated the use of rotational overtubes without dynamic rigidization in facilitating ERCP in patients with surgically altered anatomy.7 The overall success rate of ERCP performed with rotational overtubes reported in the literature was lower (65%) than that observed for dynamic rigidizing overtubes (90.9%) in our sample. However, additional studies assessing the efficacy of rigidizing overtubes in ERCP are required before further conclusions can be drawn given the small size of our sample.

Figure 1. Endoscopic configuration (A) to reach choledochojejunostomy. Low-grade biliary stricture (B, C) with an uncovered metal stent placed across choledochojejunostomy stricture (D).
Figure 2. Choledochojejunostomy stricture (yellow arrow in A) undergoing balloon dilation (B, C) and double pigtail stent placement (D).
Figure 3. The colonoscope (not visualized) and rigidizing overtube were advanced to the choledochojejunal anastomosis. The colonoscope (A) was withdrawn and a therapeutic endoscope (B) was placed through the rigidizing overtube. The preexisting stents were removed (C) and wire-guided cannulation/cholangiography was conducted (C) with subsequent stent insertion (D).
Figure 4. Dynamic rigidizing overtube in its flexible conformation.
Figure 5. Dynamic rigidizing overtube in its rigidized conformation.

Device-assisted enteroscopy has emerged as the leading modality for reaching the enterobiliary anastomosis and facilitating ERCP in patients with surgically altered anatomy.6,810 However, both single-balloon and double-balloon enteroscopes have longer working lengths and smaller working channels, which preclude the utilization of standard ERCP devices and larger caliber stents. Contrastingly, colonoscopes and short double-balloon enteroscopes can provide additional length while maintaining compatibility with some devices and allow larger caliber stent placement, but lack an elevator for therapeutic intervention. More recently, EUS-guided enteroenterostomy has emerged as a possible solution to reaching the anastomotic site that may enable appropriate device utilization with a standard duodenoscope and facilitate cannulation with an elevator.12,15,20 In addition, the use of rigidizing overtubes, as demonstrated in this study, may allow adequate access to the anastomotic site for biliary intervention.19

Our sample furnished limited data on the endoscopic evaluation and management of the pancreas in post-PD anatomy. However, prior literature has demonstrated limited technical success in post-PD patients.17,18 Similar technical limitations in traversing the afferent limb are heightened in pancreatic evaluations given the longer length of the afferent limb that is required to reach the pancreaticojejunostomy. This has led to the development of EUS-guided pancreatic interventions, including enteroenterostomy, anterograde stenting, and the rendezvous technique. A recent study compared the safety and efficacy of EUS-PDD and enteroscopy-assisted endoscopic retrograde pancreatography (e-ERP) for the management of pancreatic-related adverse events in patients with post-PD anatomy.16 EUS-PDD had a higher technical success rate than e-ERP (92.5% vs. 20%). However, there were significantly more adverse events in patients who received EUS-PDD than in those who received e-ERP (35% vs. 2.9%). While improvements are necessary to reduce the occurrence of procedure-related adverse events when performing EUS-PDD, it is emerging as a promising alternative to the traditional methods of pancreatic management in the post-PD population.

A limitation of this study is that it was a retrospective analysis conducted at a single tertiary care center. The study was also limited by a relatively small number of patients. Although there were a larger number of total ERCPs than in prior studies, some patients received multiple ERCPs. Patients with prior interventions including stent placement may serve as a roadmap for identification of choledochojejunal anastomosis, facilitating a subsequent successful intervention. As a result, the number of repeated ERCPs may have biased our technical success rate. In addition, as a large comprehensive cancer center, post-surgical anatomy may be more commonly encountered at our center than at other centers. As such, the reported technical and clinical success rates at our center may not be generalizable at a population level. Moreover, although the utilization of a rigidizing overtube demonstrated high technical success, the device was used in a limited number of patients. Finally, the number of patients in our sample referred for pancreatic evaluation was low. As a result, it is difficult to draw any conclusions regarding ERCP in post-PD patients for pancreatic indications from our study. Larger studies are required to further assess the utility of rigidizing overtubes in patients with surgically altered anatomy. Additional studies will also be required to evaluate conventional ERCP for pancreatic indications and to assess the generalizability of our results across samples in post-surgical patients.

In conclusion, ERCP is an effective therapeutic biliary procedure in post-PD patients. This study demonstrates the successful use of a rigidizing overtube in facilitating post-PD ERCP. However, post-PD ERCP remains a technically challenging procedure. Altered anatomy may preclude successful navigation of the afferent limb, given the additional length that needs to be traversed along with sharp angulation and looping in the gastrointestinal tract. Moreover, the lack of devices specifically designed for post-surgical anatomy poses an additional challenge. However, additional devices and techniques, including balloon-assisted enteroscopy, EUS-guided techniques, and rigidizing overtubes may be potential solutions to assist in post-PD patients requiring ERCP. In particular, the use of a rigidizing overtube may assist in straightening the angulation, preventing loop formation, and enhancing stability to reach the anastomotic site and facilitate the intervention. However, further studies will need to be conducted to evaluate the use of rigidizing overtubes in post-PD ERCP patients.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

No potential conflict of interest relevant to this article was reported.

  1. Karim SAM, Abdulla KS, Abdulkarim QH, Rahim FH. The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): cross sectional study. Int J Surg. 2018;52:383-7.
    Pubmed CrossRef
  2. Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001;136:391-8.
    Pubmed CrossRef
  3. House MG, Cameron JL, Schulick RD, Campbell KA, Sauter PK, Coleman J, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg. 2006;243:571-6; discussion 576-8.
    Pubmed KoreaMed CrossRef
  4. Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, Harmsen WS, Farnell MB. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg. 2007;11:1704-11.
    Pubmed CrossRef
  5. Zhang LY, Irani S, Khashab MA. Biliary endoscopy in altered anatomy. Gastrointest Endosc Clin N Am. 2022;32:563-82.
    Pubmed CrossRef
  6. Tanisaka Y, Ryozawa S, Mizuide M, Araki R, Fujita A, Ogawa T, et al. Status of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: systematic review and meta-analysis on biliary interventions. Dig Endosc. 2021;33:1034-44.
    Pubmed CrossRef
  7. Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77:593-600.
    Pubmed CrossRef
  8. Itokawa F, Itoi T, Ishii K, Sofuni A, Moriyasu F. Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection. Dig Endosc. 2014;26 Suppl 2:136-43.
    Pubmed CrossRef
  9. Inamdar S, Slattery E, Sejpal DV, Miller LS, Pleskow DK, Berzin TM, et al. Systematic review and meta-analysis of single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy. Gastrointest Endosc. 2015;82:9-19.
    Pubmed CrossRef
  10. Kurzynske FC, Romagnuolo J, Brock AS. Success of single-balloon enteroscopy in patients with surgically altered anatomy. Gastrointest Endosc. 2015;82:319-24.
    Pubmed CrossRef
  11. Skinner M, Popa D, Neumann H, Wilcox CM, Mönkemüller K. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy. 2014;46:560-72.
    Pubmed CrossRef
  12. Ichkhanian Y, Yang J, James TW, Baron TH, Irani S, Nasr J, et al. EUS-directed transenteric ERCP in non-Roux-en-Y gastric bypass surgical anatomy patients (with video). Gastrointest Endosc. 2020;91:1188-94.e2.
    Pubmed CrossRef
  13. Basiliya K, Veldhuijzen G, Gerges C, Maubach J, Will U, Elmunzer BJ, et al. Endoscopic retrograde pancreatography-guided versus endoscopic ultrasound-guided technique for pancreatic duct cannulation in patients with pancreaticojejunostomy stenosis: a systematic literature review. Endoscopy. 2021;53:266-76.
    Pubmed CrossRef
  14. Gasmi M, Gonzalez JM, Barthet M. Endoscopic ultrasound-directed transgastrojejunal ERCP: a new technique to treat biliary stricture through the afferent limb after Whipple surgery. Endoscopy. 2020;52:E441-2.
    Pubmed CrossRef
  15. Mutignani M, Forti E, Larghi A, Pugliese F, Cintolo M, Massad M, et al. Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy. Endoscopy. 2019;51:1146-50.
    Pubmed CrossRef
  16. Chen YI, Levy MJ, Moreels TG, Hajijeva G, Will U, Artifon EL, et al. An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery. Gastrointest Endosc. 2017;85:170-7.
    Pubmed CrossRef
  17. Chahal P, Baron TH, Topazian MD, Petersen BT, Levy MJ, Gostout CJ. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy. 2006;38:1241-5.
    Pubmed CrossRef
  18. Farrell J, Carr-Locke D, Garrido T, Ruymann F, Shields S, Saltzman J. Endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy for benign and malignant disease: indications and technical outcomes. Endoscopy. 2006;38:1246-9.
    Pubmed CrossRef
  19. Wei MT, Hwang JH, Watson RR, Park W, Friedland S. Novel rigidizing overtube for colonoscope stabilization and loop prevention (with video). Gastrointest Endosc. 2021;93:740-9.
    Pubmed CrossRef
  20. Ullah KI, Bhardwaj M, Ho S. Altered anatomy: an EUS-guided placement of a lumen-apposing metal stent for successful ERCP following Whipple procedure (with video). Endosc Ultrasound. 2022;11:237-8.
    Pubmed KoreaMed CrossRef