Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

Figure 1 Billroth II gastrectomy and variations of reconstruction. A: Antiperistaltic type. The entry of the afferent limb is located near the lesser curvature; B: Isoperistaltic type. The entry site is located near the greater curvature; C: Retrocolic reconstruction. The afferent limb is shorter than that in antecolic reconstruction; D: Antecolic reconstruction. The afferent limb is significantly longer than that in retrocolic reconstruction; E: Roux-en-Y reconstruction involves the longest limb among all Billroth II gastrectomy techniques; F: Braun jejunojejunostomy anastomosis creates a confusing endoscopic view to reach the afferent limb.

Figure 2 Various reconstructions of pancreaticoduodenectomy (Whipple’s procedure). A: Conventional Whipple’s procedure; The afferent limb is near the lesser curve; B: Pylorus-preserving pancreaticoduodenectomy; C: Braun anastomosis may create a confusing endoscopic view.

Figure 3 Other types of reconstruction. A: Roux-en-Y gastric bypass; B: Hepaticojejunostomy in liver transplant, pancreaticobiliary maljunction, or bile duct cancer.

Figure 4 Technique to identify afferent limb. A: Intraluminal indigo carmine injection; B: CO₂ insufflation guidance.

Figure 5 Endoscopic EUS-guided ERCP and laparoscopic-assisted ERCP in Roux-en-Y gastric bypass. A: EUS-guided transgastric fistula by luminal-apposing metallic stents; B: EUS-guided jejunogastrostomy stent with conventional ERCP; C: EUS-directed transgastric ERCP for Roux-en-Y reconstruction; D: EUS-guided sutured gastropexy for transgastric ERCP; E: Laparoscopic-assisted ERCP. ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Ultrasonography.