ERCP in Postsurgical Patients

  • Meir MizrahiEmail author
  • Tyler M. Berzin
  • Jeffrey D. Mosko
  • Douglas Pleskow


The wide array of upper gastrointestinal tract surgeries and the rising number of patients undergoing bariatric surgery for weight loss creates a significant challenge for therapeutic endoscopists attempting to perform endoscopic pancreaticobiliary procedures.

ERCP is an essential tool for a wide variety of pancreaticobiliary diseases, ranging from bile duct stones, to pancreatic adenocarcinoma to postoperative strictures of the common bile duct, including anastomosis after liver transplant.

The rate of successful ERCP with normal anatomy often exceeds 95 % in expert hands. When the upper gastrointestinal anatomy is altered, ERCP success rate declines substantially due to difficulty reaching the ampulla or the pancreaticobiliary anastomosis, and in certain cases, the difficulty of performing biliary procedures using nonstandard endoscopic equipment including balloon enteroscopes and long-length biliary catheters. Despite the challenges posed, the need for successful endoscopic approaches in these patients continues to grow over time.


Anatomy Altered Billroth II Roux-en-Y Endoscopic retrograde cholangiopancreatography (ERCP) Balloon Enteroscopy Duodenoscope Bariatric Afferent 

Supplementary material

Video 6.1

Single balloon enteroscopy assisted ERCP (MP4 149,576 kb).


  1. 1.
    Cotton PB. Digestive endoscopy in five decades. Clin Med. 2005;5(6):614–20.CrossRefGoogle Scholar
  2. 2.
    Freeman ML, Guda NM. Endoscopic biliary and pancreatic sphincterotomy. Curr Treat Options Gastroenterol. 2005;8(2):127–34.CrossRefPubMedGoogle Scholar
  3. 3.
    Freeman ML, Guda NM. ERCP cannulation: a review of reported techniques. Gastrointest Endosc. 2005;61(1):112–25.CrossRefPubMedGoogle Scholar
  4. 4.
    Forbes A, Cotton PB. ERCP and sphincterotomy after Billroth II gastrectomy. Gut. 1984;25(9):971–4.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Santoro E. The history of gastric cancer: legends and chronicles. Gastric Cancer. 2005;8(2):71–4.CrossRefPubMedGoogle Scholar
  6. 6.
    Pach R, Orzel-Nowak A, Scully T. Ludwik Rydygier--contributor to modern surgery. Gastric Cancer. 2008;11(4):187–91.CrossRefPubMedGoogle Scholar
  7. 7.
    Porter HW, Claman ZB. A preliminary report on the advantages of a small stoma in partial gastrectomy for ulcer. Ann Surg. 1949;129(4):417–28.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Petri G. Our surgical heritage: the tragic destiny of the surgeon. Eugen Alexander Polya (1876-1944). Zentralbl Chir. 1985;110(1):46–52.PubMedGoogle Scholar
  9. 9.
    Demarquay JF, Dumas R, Buckley MJ, Conio M, Zanaldi H, Hastier P, et al. Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Ital J Gastroenterol Hepatol. 1998;30(3):297–300.PubMedGoogle Scholar
  10. 10.
    Aabakken L, Holthe B, Sandstad O, Rosseland A, Osnes M. Endoscopic pancreaticobiliary procedures in patients with a Billroth II resection: a 10-year follow-up study. Ital J Gastroenterol Hepatol. 1998;30(3):301–5.PubMedGoogle Scholar
  11. 11.
    Aabakken L, Chak A. Internet for endoscopists: surf or drown? Gastrointest Endosc. 1998;47(5):423–5.PubMedGoogle Scholar
  12. 12.
    Kim MH, Lee SK, Lee MH, Myung SJ, Yoo BM, Seo DW, et al. Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope. Endoscopy. 1997;29(2):82–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Byun JW, Kim JW, Sung SY, Jung HY, Jeon HK, Park HJ, et al. Usefulness of forward-viewing endoscope for endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Clin Endosc. 2012;45(4):397–403.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Prat F, Fritsch J, Choury AD, Meduri B, Pelletier G, Buffet C. Endoscopic sphincteroclasy: a useful therapeutic tool for biliary endoscopy in Billroth II gastrectomy patients. Endoscopy. 1997;29(2):79–81.CrossRefPubMedGoogle Scholar
  15. 15.
    Faylona JM, Qadir A, Chan AC, Lau JY, Chung SC. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy. 1999;31(7):546–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Lin LF, Siauw CP, Ho KS, Tung JC. ERCP in post-Billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol. 1999;94(1):144–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Osnes M, Rosseland AR, Aabakken L. Endoscopic retrograde cholangiography and endoscopic papillotomy in patients with a previous Billroth-II resection. Gut. 1986;27(10):1193–8.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Costamagna G, Loperfido S, Familiari P. Endoscopic retrograde cholangiopancreatography ERCP after Billroth II reconstruction. Howell DA, Travis AC (eds). UpToDate Available from:
  19. 19.
    Bove V, Tringali A, Familiari P, Gigante G, Boskoski I, Perri V, et al. ERCP in patients with prior Billroth II gastrectomy: report of 30 years’ experience. Endoscopy. 2015;47:611.CrossRefPubMedGoogle Scholar
  20. 20.
    Cicek B, Parlak E, Disibeyaz S, Koksal AS, Sahin B. Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy. J Gastroenterol Hepatol. 2007;22(8):1210–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335(13):909–18.CrossRefPubMedGoogle Scholar
  22. 22.
    Loperfido S, Angelini G, Benedetti G, Chilovi F, Costan F, De Berardinis F, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc. 1998;48(1):1–10.CrossRefPubMedGoogle Scholar
  23. 23.
    Colton JB, Curran CC. Quality indicators, including complications, of ERCP in a community setting: a prospective study. Gastrointest Endosc. 2009;70(3):457–67.CrossRefPubMedGoogle Scholar
  24. 24.
    Khan MH, Howard TJ, Fogel EL, Sherman S, McHenry L, Watkins JL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc. 2007;65(2):247–52.CrossRefPubMedGoogle Scholar
  25. 25.
    Huibregtse K. Complications of endoscopic sphincterotomy and their prevention. N Engl J Med. 1996;335(13):961–3.CrossRefPubMedGoogle Scholar
  26. 26.
    Cohen SA, Siegel JH, Kasmin FE. Complications of diagnostic and therapeutic ERCP. Abdom Imaging. 1996;21(5):385–94.CrossRefPubMedGoogle Scholar
  27. 27.
    Nakahara K, Horaguchi J, Fujita N, Noda Y, Kobayashi G, Ito K, et al. Therapeutic endoscopic retrograde cholangiopancreatography using an anterior oblique-viewing endoscope for bile duct stones in patients with prior Billroth II gastrectomy. J Gastroenterol. 2009;44(3):212–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Skinner M, Popa D, Neumann H, Wilcox CM, Monkemuller K. ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy. 2014;46(7):560–72.CrossRefPubMedGoogle Scholar
  29. 29.
    Costamagna G, Mutignani M, Perri V, Gabrielli A, Locicero P, Crucitti F. Diagnostic and therapeutic ERCP in patients with Billroth II gastrectomy. Acta Gastroenterol Belg. 1994;57(2):155–62.PubMedGoogle Scholar
  30. 30.
    Park CH, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS. Cap-assisted ERCP in patients with a Billroth II gastrectomy. Gastrointest Endosc. 2007;66(3):612–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Lee YT. Cap-assisted endoscopic retrograde cholangiopancreatography in a patient with a Billroth II gastrectomy. Endoscopy. 2004;36(7):666.CrossRefPubMedGoogle Scholar
  32. 32.
    Trindade AJ, Mella JM, Slattery E, Cohen J, Dickstein J, Garud SS, et al. Use of a cap in single-balloon enteroscopy-assisted endoscopic retrograde cholangiography. Endoscopy. 2015;47:453.CrossRefPubMedGoogle Scholar
  33. 33.
    Osoegawa T, Motomura Y, Akahoshi K, Higuchi N, Tanaka Y, Hisano T, et al. Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography. World J Gastroenterol. 2012;18(46):6843–9.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Choi YR, Han JH, Cho YS, Han HS, Chae HB, Park SM, et al. Efficacy of cap-assisted endoscopy for routine examining the ampulla of Vater. World J Gastroenterol. 2013;19(13):2037–43.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Cremer M, Gulbis A, Touissaint J, de Toeuf J, van Laethem A, Hermanus A, et al. Endoscopic sphincterotomy. A Belgian experience (1976) (author’s transl). Acta Gastroenterol Belg. 1977;40(1-2):41–54.PubMedGoogle Scholar
  36. 36.
    Hintze RE, Adler A, Veltzke W, Abou-Rebyeh H. Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with Billroth II or Roux-en-Y gastrojejunostomy. Endoscopy. 1997;29(2):69–73.CrossRefPubMedGoogle Scholar
  37. 37.
    Costamagna G, Gabrielli A, Mutignani M, Perri V, Buononato M, Crucitti F. Endoscopic diagnosis and treatment of malignant biliary strictures: review of 505 patients. Acta Gastroenterol Belg. 1993;56(2):201–6.PubMedGoogle Scholar
  38. 38.
    Ricci E, Bertoni G, Conigliaro R, Contini S, Mortilla MG, Bedogni G. Endoscopic sphincterotomy in Billroth II patients: an improved method using a diathermic needle as sphincterotome and a nasobiliary drain as guide. Gastrointest Endosc. 1989;35(1):47–50.CrossRefPubMedGoogle Scholar
  39. 39.
    Maydeo A, Bhandari S. Balloon sphincteroplasty for removing difficult bile duct stones. Endoscopy. 2007;39(11):958–61.CrossRefPubMedGoogle Scholar
  40. 40.
    Peters JH, Carey LC. Historical review of pancreaticoduodenectomy. Am J Surg. 1991;161(2):219–25.CrossRefPubMedGoogle Scholar
  41. 41.
    Traverso LW, Longmire Jr WP. Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet. 1978;146(6):959–62.PubMedGoogle Scholar
  42. 42.
    Bassi C, Falconi M, Molinari E, Salvia R, Butturini G, Sartori N, et al. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg. 2005;242(6):767–71. discussion 71–73.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Duffas JP, Suc B, Msika S, Fourtanier G, Muscari F, Hay JM, et al. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg. 2005;189(6):720–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Berger AC, Howard TJ, Kennedy EP, Sauter PK, Bower-Cherry M, Dutkevitch S, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg. 2009;208(5):738–47. discussion 47–49.CrossRefPubMedGoogle Scholar
  45. 45.
    Tran K, Van Eijck C, Di Carlo V, Hop WC, Zerbi A, Balzano G, et al. Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial. Ann Surg. 2002;236(4):422–8. discussion 8.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Reissman P, Perry Y, Cuenca A, Bloom A, Eid A, Shiloni E, et al. Pancreaticojejunostomy versus controlled pancreaticocutaneous fistula in pancreaticoduodenectomy for periampullary carcinoma. Am J Surg. 1995;169(6):585–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Yang SH, Dou KF, Sharma N, Song WJ. The methods of reconstruction of pancreatic digestive continuity after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg. 2011;35(10):2290–7.CrossRefPubMedGoogle Scholar
  48. 48.
    Chahal P, Baron TH, Topazian MD, Petersen BT, Levy MJ, Gostout CJ. Endoscopic retrograde cholangiopancreatography in post-Whipple patients. Endoscopy. 2006;38(12):1241–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Maaser C, Lenze F, Bokemeyer M, Ullerich H, Domagk D, Bruewer M, et al. Double balloon enteroscopy: a useful tool for diagnostic and therapeutic procedures in the pancreaticobiliary system. Am J Gastroenterol. 2008;103(4):894–900.CrossRefPubMedGoogle Scholar
  50. 50.
    Itoi T, Ishii K, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, et al. Single balloon enteroscopy-assisted ERCP using rendezvous technique for sharp angulation of Roux-en-Y limb in a patient with bile duct stones. Diagn Ther Endosc. 2009;2009:154084.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Chua TJ, Kaffes AJ. Balloon-assisted enteroscopy in patients with surgically altered anatomy: a liver transplant center experience (with video). Gastrointest Endosc. 2012;76(4):887–91.CrossRefPubMedGoogle Scholar
  52. 52.
    Monkemuller K, Fry LC, Bellutti M, Neumann H, Malfertheiner P. ERCP with the double balloon enteroscope in patients with Roux-en-Y anastomosis. Surg Endosc. 2009;23(9):1961–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Itoi T, Ishii K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, et al. Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis. Surg Endosc. 2011;25(3):713–21.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Cho S, Kamalaporn P, Kandel G, Kortan P, Marcon N, May G. ‘Short’ double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract. Can J Gastroenterol. 2011;25(11):615–9.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    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.CrossRefPubMedGoogle Scholar
  56. 56.
    Lopes TL, Wilcox CM. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Gastroenterol Clin North Am. 2010;39(1):99–107.CrossRefPubMedGoogle Scholar
  57. 57.
    Gostout CJ, Bender CE. Cholangiopancreatography, sphincterotomy, and common duct stone removal via Roux-en-Y limb enteroscopy. Gastroenterology. 1988;95(1):156–63.PubMedGoogle Scholar
  58. 58.
    Elton E, Hanson BL, Qaseem T, Howell DA. Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients. Gastrointest Endosc. 1998;47(1):62–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Wright BE, Cass OW, Freeman ML. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Gastrointest Endosc. 2002;56(2):225–32.CrossRefPubMedGoogle Scholar
  60. 60.
    Kikuyama M, Sasada Y, Matsuhashi T, Ota Y, Nakahodo J. ERCP after Roux-en-Y reconstruction can be carried out using an oblique-viewing endoscope with an overtube. Dig Endosc. 2009;21(3):180–4.CrossRefPubMedGoogle Scholar
  61. 61.
    Schreiner MA, Chang L, Gluck M, Irani S, Gan SI, Brandabur JJ, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc. 2012;75(4):748–56.CrossRefPubMedGoogle Scholar
  62. 62.
    Baron TH, Vickers SM. Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Gastrointest Endosc. 1998;48(6):640–1.CrossRefPubMedGoogle Scholar
  63. 63.
    Gutierrez JM, Lederer H, Krook JC, Kinney TP, Freeman ML, Jensen EH. Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass. J Gastrointest Surg. 2009;13(12):2170–5.CrossRefPubMedGoogle Scholar
  64. 64.
    Schreiner MA, Chang L, Gluck M, Irani S, Gan SI, Brandabur JJ, Thirlby R, Moonka R, Kozarek RA, Ross AS. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc. 2012 Apr;75(4):748-56. doi:  10.1016/j.gie.2011.11.019. Epub 2012 Jan 31. PubMed PMID: 22301340.Google Scholar
  65. 65.
    Parlak E, Ciçek B, Dişibeyaz S, et al. Endoscopic retrograde cholangiography by double balloon enteroscopy in patients with Roux-en-Y hepaticojejunostomy. Surg Endosc. 2010;24(2):466–70. doi: 10.1007/s00464-009-0591-3.CrossRefPubMedGoogle Scholar
  66. 66.
    Neumann H, Fry LC, Meyer F, Malfertheiner P, Monkemuller K. Endoscopic retrograde cholangiopancreatography using the single balloon enteroscope technique in patients with Roux-en-Y anastomosis. Digestion. 2009;80(1):52–7.CrossRefPubMedGoogle Scholar
  67. 67.
    Tomizawa Y, Sullivan CT, Gelrud A. Single balloon enteroscopy (SBE) assisted therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with roux-en-y anastomosis. Dig Dis Sci. 2014;59(2):465–70.CrossRefPubMedGoogle Scholar
  68. 68.
    Li K, Huang YH, Yao W, Chang H, et al. Adult colonoscopy or single-balloon enteroscopy-assisted ERCP in long-limb surgical bypass patients. Clin Res Hepatol Gastroenterol. 2014;38(4):513–9.CrossRefPubMedGoogle Scholar
  69. 69.
    Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et al. A multicenter, US 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(4):593–600.CrossRefPubMedGoogle Scholar
  70. 70.
    Itoi T, Ishii K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T, et al. Single-balloon enteroscopy-assisted ERCP in patients with Billroth II gastrectomy or Roux-en-Y anastomosis (with video). Am J Gastroenterol. 2010;105(1):93–9.CrossRefPubMedGoogle Scholar
  71. 71.
    Saleem A, Baron TH, Gostout CJ, Topazian MD, Levy MJ, Petersen BT, et al. Endoscopic retrogradecholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy. Endoscopy. 2010;42(8):656–60.CrossRefPubMedGoogle Scholar
  72. 72.
    Azeem N, Tabibian JH, Baron TH, Orhurhu V, Rosen CB, Petersen BT, et al. Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis. Gastrointest Endosc. 2013;77(4):568–77.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Meir Mizrahi
    • 1
    Email author
  • Tyler M. Berzin
    • 1
  • Jeffrey D. Mosko
    • 2
  • Douglas Pleskow
    • 1
  1. 1.Division of Gastroenterology, Advanced Endoscopy Center, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Department of MedicineUniversity of TorontoTorontoCanada

Personalised recommendations