Spontaneous migration of a dedicated plastic stent after endoscopic ultrasound-guided hepaticogastrostomy in a patient with surgically altered anatomy: a case report.

Objective: We report a case of spontaneous migration of a dedicated plastic stent after endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) in a patient with surgically altered anatomy. Patient: The patient was a male in his 70s. He underwent EUS-HGS with the successful insertion of a dedicated plastic stent and had no obvious postprocedural complications. However, nine days after the procedure, the patient visited our hospital because of abdominal pain, fever, and stent excretion. We performed EUS-HGS with antegrade stenting, after which the patient had no further complications. Conclusion: Stent migration is considered a complication requiring caution when performing EUS-HGS in patients with surgically altered anatomy.

Endoscopic approach for biliopancreatic disease after pancreaticoduodenectomy: a 10-year single-center experience.

BACKGROUND AND AIM: In surgically altered anatomy (SAA), endoscopic retrograde cholangiopancreatography (ERCP) can be challenging, and it remains debatable the choice of the optimal endoscopic approach within this context. We aim to show our experience and evaluate the technical and clinical success of endoscopic treatment performed in the setting of adverse events (AE) after pancreaticoduodenectomy (PD). METHODS: This study was conducted on a retrospective cohort of patients presenting biliopancreatic complications after PD from 01/01/2012 to 31/12/2022. All patients underwent ERCP at our Endoscopy Unit. Clinical, instrumental data, and characteristics of endoscopic treatments were collected. RESULTS: 133 patients were included (80 M, mean age = 65 y.o.) with a total of 296 endoscopic procedures (median = 2 procedures/treatment). The indications for ERCP were mainly biliary AE (76 cases, 57.1%). Technical success was obtained in 121 patients of 133 (90.9%). 112 out of 133 (84.2%) obtained clinical success. Nine patients out of 112 (8%) experienced AEs. Clinical success rates were statistically different between patients with biliary or pancreatic disease (93.4% vs 73.6%, p < 0.0001). Septic patients were 38 (28.6%) and showed a worse prognosis than non-septic ones (clinical success: 65.7% vs 91.5%, p = 0.0001). During follow-up, 9 patients (8%), experienced recurrence of the index biliopancreatic disease with a median onset at 20 months (IQR 6-40.1). CONCLUSION: Our case series demonstrated that the use of a pediatric colonoscope in ERCP procedures for patients with AEs after PD is both safe and effective in treating the condition, even in a long-term follow-up.

Simplified single-session EUS-guided transhepatic antegrade stone removal for management of choledocholithiasis in patients with surgically altered anatomy.

Background: Endoscopic ultrasound (EUS)-guided transhepatic antegrade stone removal (TASR) has been reserved for choledocholithiasis after failed endoscopic retrograde cholangiopancreatography (ERCP) in recent years. The aim of this study was to evaluate the techniques, feasibility, and safety of simplified single-session EUS-TASR for choledocholithiasis in patients with surgically altered anatomy (SAA). Methods: A retrospective database of patients with SAA and choledocholithiasis from the Second Hospital of Hebei Medical University (Shijiazhuang, China) between August 2020 and February 2023 was performed. They all underwent single-session EUS-TASR after ERCP failure. Basic characteristics of the patients and details of the procedures were collected. The success rates and adverse events were evaluated and discussed. Results: During the study period, 13 patients underwent simplified single-session EUS-TASR as a rescue procedure (8 males, median age, 64.0 [IQR, 48.5-69.5] years). SAA consisted of four Whipple procedures, one Billroth II gastrectomy, four gastrectomy with Roux-en-Y anastomoses, and four hepaticojejunostomy with Roux-en-Y anastomoses. The technical success rate was 100% and successful bile duct stone removal was achieved in 12 of the patients (92.3%). Adverse events occurred in two patients (15.4%), while one turned to laparoscopic surgery and the other was managed conservatively. Conclusions: Simplified single-session EUS-TASR as a rescue procedure after ERCP failure appeared to be effective and safe in the management of choledocholithiasis in patients with SAA. But further evaluation of this technique is still needed, preferably through prospective multicenter trials.

Transenteric Endoscopic Retrograde Cholangiopancreatography in Non-roux-en-Y Surgically Altered Anatomy.

EDEE is a relatively safe and effective procedure when performed by expert endoscopists to establish pancreaticobiliary access in patients who have failed, or are not candidates for, traditional ERCP or alternative drainage modalities. Careful preprocedural planning with attention to the patient's specific postsurgical anatomy can optimize outcomes and minimize AEs.

Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry.

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Italian Survey on Endoscopic Biliary Drainage Approach in Patients with Surgically Altered Anatomy.

Background and Objectives: Biliary drainage (BD) in patients with surgically altered anatomy (SAA) could be obtained endoscopically with different techniques or with a percutaneous approach. Every endoscopic technique could be challenging and not clearly superior over another. The aim of this survey is to explore which is the standard BD approach in patients with SAA. Materials and Methods: A 34-question online survey was sent to different Italian tertiary and non-tertiary endoscopic centers performing interventional biliopancreatic endoscopy. The core of the survey was focused on the first-line and alternative BD approaches to SAA patients with benign or malignant obstruction. Results: Out of 70 centers, 39 answered the survey (response rate: 56%). Only 48.7% of them declared themselves to be reference centers for endoscopic BD in SAA. The total number of procedures performed per year is usually low, especially in non-tertiary centers; however, they have a low tendency to refer to more experienced centers. In the case of Billroth-II reconstruction, the majority of centers declared that they use a duodenoscope or forward-viewing scope in both benign and malignant diseases as a first approach. However, in the case of failure, the BD approach becomes extremely heterogeneous among centers without any technique prevailing over the others. Interestingly, in the case of Roux-en-Y, a significant proportion of centers declared that they choose the percutaneous approach in both benign (35.1%) and malignant obstruction (32.4%) as a first option. In the case of a previous failed attempt at BD in Roux-en-Y, the subsequent most used approach is the EUS-guided intervention in both benign and malignant indications. Conclusions: This survey shows that the endoscopic BD approach is extremely heterogeneous, especially in patients with Roux-en-Y reconstruction or after ERCP failure in Billroth-II reconstruction. Percutaneous BD is still taken into account by a significant proportion of centers in the case of Roux-en-Y anatomy. The total number of endoscopic BD procedures performed in non-tertiary centers is usually low, but this result does not correspond to an adequate rate of referral to more experienced centers.

Performance and safety of percutaneous cholangioscopy: a systematic review and meta-analysis.

Background: Percutaneous cholangioscopy (PerC) offers an alternative for patients with an inaccessible biliary tree. This systematic review and meta-analysis aimed to evaluate the performance of this technique. Methods: A search in Medline, Cochrane and ClinicalTrials.gov databases was performed for studies assessing PerC up to October 2022. The primary outcome was diagnostic success, defined as successful stone identification or stricture workup. Secondary outcomes included therapeutic success (stone extraction, stenting) and complication rate. A subgroup analysis compared previous-generation and modern cholangioscopes. We performed meta-analyses using a random-effects model and the results were reported as percentages with 95% confidence interval (CI). Results: Fourteen studies (682 patients) were eligible for analysis. The rate of diagnostic success was 98.7% (95%CI 97.6-99.8%; I2=31.19%) and therapeutic success was 88.6% (95%CI 82.8-94.3%; I2=74.92%). Adverse events were recorded in 17.1% (95%CI 10.7-23.5%; I2=77.56%), of which 15.9% (95%CI 9.8-21.9%; I2=75.98%) were minor and 0.6% (95%CI 0.1-1.2%; I2=0%) major. The Spyglass system showed null heterogeneity for all outcomes; compared with older-generation endoscopes it offered comparable diagnostic success, but yielded significantly superior therapeutic success (96.1%, 95%CI 90-100%; I2=0% vs. 86.4%, 95%CI 79.2-93.6%; I2=81.41%; P=0.02]. Conclusion: PerC, especially using currently available cholangioscopes, is associated with high diagnostic and therapeutic success.

Patient Radiation Exposure during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy (with Video).

BACKGROUND: Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce. METHODS: 34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected. RESULTS: Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple's duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m2) compared to C-ERCP (1600 ± 117 µGy*m2, p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose). CONCLUSIONS: Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex.

Utility of a Passive Bending Colonoscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy.

BACKGROUND AND AIM: The utility of a passive bending colonoscope (PBCS) in ERCP for patients with surgically altered anatomy has not been established. This study compared the outcome of PBCS-ERCP and balloon-assisted enteroscope (BAE)-ERCP. METHODS: This multicenter observational study included 343 patients with surgically altered anatomy who underwent ERCP. Among these, 110 underwent PBCS-ERCP and 233 underwent BAE-ERCP. Propensity score matching was applied, and a final cohort of 210 (105 in each group) with well-balanced backgrounds was analyzed. The primary outcome was the success rate of reaching anastomosis or ampulla of Vater. Secondary endpoints included the cannulation success rate, completion rate, procedure time (to reach, cannulate, complete), and adverse events. RESULTS: The success rate for reaching the target was 91.4% (96/105) with PBCS and 90.5% (95/105) with BAE (odds ratio [95% CI] 1.12, [0.44-2.89], P = 0.809). The mean time required to reach the target was significantly shorter in PBCS: 10.04 min (SD, 9.62) with PBCS versus 18.77 min (SD, 13.21) with BAE (P < 0.001). There were no differences in the success of cannulation or procedure completion, although the required times for cannulation and procedure completion were significantly shorter in PBCS. The incidence of adverse events was significantly higher in BAE (19.0%) than in PBCS (4.8%; P < 0.001). CONCLUSIONS: In patients with surgically altered anatomy, PBCS-ERCP showed promising results with shorter time to reach, cannulate, and a lower incidence of adverse events compared with BAE-ERCP. The success rate of reaching was favorable through PBCS compared with BAE. CLINICAL TRIAL REGISTRATION: UMIN000045546.

Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography in a Patient with Gastric Bypass. Report of the First Local Case

We describe the first case in our environment of endoscopic ultrasound (EUS)-assisted transgastric endoscopic retrograde cholangiopancreatography in a patient with gastric bypass surgery. The procedure was performed with a side-viewing duodenoscope through a jejunogastrostomy using apposing stents, placed with EUS assistance, and a standard technique and instruments.

Se describe el primer caso en nuestro medio de colangiopancreatografía retrógrada endoscópica transgástrica asistida por endosonografía en una paciente con cirugía de baipás gástrico. El procedimiento se realizó con duodenoscopio de visión lateral a través de una yeyunogastrostomía por stent de aposición, emplazado con asistencia endosonográfica y con una técnica e instrumental estándar.

Endoscopic Biliary Drainage in Surgically Altered Anatomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the preferred method for managing biliary obstructions. However, the prevalence of surgically modified anatomies often poses challenges, making the standard side-viewing duodenoscope unable to reach the papilla in most cases. The increasing instances of surgically altered anatomies (SAAs) result from higher rates of bariatric procedures and surgical interventions for pancreatic malignancies. Conventional ERCP with a side-viewing endoscope remains effective when there is continuity between the stomach and duodenum. Nonetheless, percutaneous transhepatic biliary drainage (PTBD) or surgery has historically been used as an alternative for biliary drainage in malignant or benign conditions. The evolving landscape has seen various endoscopic approaches tailored to anatomical variations. Innovative methodologies such as cap-assisted forward-viewing endoscopy and enteroscopy have enabled the performance of ERCP. Despite their utilization, procedural complexities, prolonged durations, and accessibility challenges have emerged. As a result, there is a growing interest in novel enteroscopy and endoscopic ultrasound (EUS) techniques to ensure the overall success of endoscopic biliary drainage. Notably, EUS has revolutionized this domain, particularly through several techniques detailed in the review. The rendezvous approach has been pivotal in this field. The antegrade approach, involving biliary tree puncturing, allows for the validation and treatment of strictures in an antegrade fashion. The EUS-transmural approach involves connecting a tract of the biliary system with the GI tract lumen. Moreover, the EUS-directed transgastric ERCP (EDGE) procedure, combining EUS and ERCP, presents a promising solution after gastric bypass. These advancements hold promise for expanding the horizons of comprehensive and successful biliary drainage interventions, laying the groundwork for further advancements in endoscopic procedures.

Endoscopic Management of Bleeding in Altered Anatomy after Upper Gastrointestinal Surgery.

Postoperative non variceal upper gastrointestinal haemorrhage may occur early or late and affect a variable percentage of patients-up to about 2%. Most cases of intraluminal bleeding are an indication for urgent Esophagogastroduodenoscopy (EGD) and require endoscopic haemostatic treatment. In addition to the approach usually adopted in non-variceal upper haemorrhages, these cases may be burdened with difficulties in terms of anastomotic tissue, angled positions, and the risk of further complications. There is also extreme variability related to the type of surgery performed, in the context of oncological disease or bariatric surgery. At the same time, the world of haemostatic devices available in digestive endoscopy is increasing, meeting high efficacy rates and attempting to treat even the most complex cases. Our narrative review summarises the current evidence in terms of different approaches to endoscopic haemostasis in upper bleeding in altered anatomy after surgery, proposing an up-to-date guidance for endoscopic clinicians and at the same time, highlighting areas of future scientific research.

Endoscopic Ultrasound-Guided Pancreatic Duct Interventions.

Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is one of the most challenging procedures in therapeutic endoscopy. Technical success is lower than for other therapeutic EUS procedures. However, when successful in a clear clinical indication, this procedure can offer a useful therapeutic alternative and improves the overall clinical success of the endoscopic approach. Current challenges include the standardization of clinical indications and of the techniques used for accessing the pancreatic duct, the strategy for mid-term and long-term management, and definition of the scope of the training that should be offered to a few highly experienced endoscopists.

Motorized spiral enteroscopy: effectiveness when used for new indications.

Background and study aims: Motorized spiral enteroscopy is proven to be effective in antegrade and retrograde enteroscopy. Nevertheless, little is known about its use in less common indications. The aim of this study was to identify new indications for the motorized spiral enteroscope. Methods: Monocentric retrospective analysis of 115 patients who underwent enteroscopy using PSF-1 motorized spiral enteroscope between January 2020 and December 2022. Results: A total of 115 patients underwent PSF-1 enteroscopy. 44 (38%) were antegrade procedures and 24 (21%) were retrograde procedures in patients with normal gastrointestinal anatomy with conventional enteroscopy indications. The remaining 47 (41%) patients underwent PSF-1 procedures for secondary less conventional indications: n=25 (22%) enteroscopy-assisted ERCP, n=8 (7%) endoscopy of the excluded stomach after Roux-en-Y gastric bypass, n=7 (6%) retrograde enteroscopy after previous incomplete conventional colonoscopy and n=7 (6%) antegrade panenteroscopy of the entire small bowel. In this group of secondary indications, technical success rate was significantly lower (72.5%) as compared to technical success rates in the conventional groups (98-100%, p<0.001 Chi-square). Minor adverse events occurred in 17/115 patients (15%), all treated conservatively (AGREE I and II). Conclusion: This study demonstrates the capabilities of PSF-1 motorized spiral enteroscope for secondary indications. PSF-1 is useful to complete colonoscopy in case of long redundant colon, to reach the excluded stomach after Roux-en-Y gastric bypass, to perform unidirectional pan-enteroscopy and to perform ERCP in patients with surgically altered anatomy. However, technical success rates are lower as compared to conventional antegrade and retrograde enteroscopy procedures, with only minor adverse events.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP.

BACKGROUND: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. METHODS: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. RESULTS: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76 (90%) procedures and clinical success rate of 30/34 (88%) patients. Mild adverse event rate was 8/76 (11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30 (80%) procedures (P = 0.194 vs. biliary SBE-ERCP) and clinical success rate of 11/17 (65%) patients (P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30 (20%) (P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. CONCLUSIONS: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches.

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred modality for drainage of the obstructed biliary tree. In patients with surgically altered anatomy, ERCP using standard techniques may not be feasible. Enteroscope assisted ERCP is usually employed with variable success rate. With advent of endoscopic ultrasound (EUS), biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective. In this narrative review, we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a technical review.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

Successful Intubation Using a Cap-Assisted Colonoscope for Endoscopic Retrograde Cholangiopancreatography in Patients Undergoing Roux-en-Y Reconstruction.

Endoscopic retrograde cholangiopancreatography (ERCP) is challenging in patients undergoing Roux-en-Y (REY) reconstruction; although balloon-assisted enteroscopy is the first-line treatment, it is not always available considering equipment and expertise. We aimed to evaluate the feasibility of using a cap-assisted colonoscope as the primary approach for ERCP in REY reconstruction. We included 47 patients with REY who underwent ERCP using a cap-assisted colonoscope between January 2017 and February 2022. The primary outcome was intubation success for ERCP using a cap-assisted colonoscope during REY reconstruction. The secondary outcomes were cannulation success, procedure-related adverse events, and variables affecting successful intubation. Comparing side-to-side jejunojejunostomy (SS-JJ) and side-to-end jejunojejunostomy (SE-JJ) groups, the intubation success rate using a cap-assisted colonoscope in the SS-JJ group was higher than that in the SE-JJ group (34 of 38 (89.5%) vs. 1 of 9 (11.1%), p < 0.001). Successful intubation was achieved in 37 (97.4%) and 8 (88.9%) patients in the SS-JJ and SE-JJ groups, respectively, after applying the rescue technique using a balloon-assisted enteroscope for failed ERCP using only a colonoscope. No perforation occurred. Multivariable analysis showed that SS-JJ was a predictive factor for successful intubation (odds ratio [95% confidence interval] = 37.06 [3.91-925.56], p = 0.005). Usage of a cap-assisted colonoscope can be crucial for ERCP in patients undergoing REY reconstruction. Anatomically, SS-JJ can facilitate easy and accurate identification of the afferent limb and a highly successful ERCP using a cap-assisted colonoscope.

Techniques and Outcomes of Endoscopic Ultrasound Guided-Pancreatic Duct Drainage (EUS- PDD).

Endoscopic ultrasound guided-pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed.