Techniques for scope insertion by utilizing the "suture line on the jejunojejunostomy" in balloon enteroscopeassisted ercp in patients with surgically altered anatomies

The development of the balloon enteroscope has facilitated the performance of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pancreatobiliary diseases in patients with surgically altered anatomies. However, no standard procedure has been established. Therefore, scope insertion to the target site (papilla of Vater or bilioenteric anastomosis) in patients with complicated reconstruction (e.g., pancreatoduodenectomy with modified Child method, Billroth reconstruction with gastrectomy, and Roux-en-Y reconstruction with or without gastrectomy) is performed through trial and error. Our scope insertion technique is to utilize the "suture line on the jejunojejunostomy" as a marker for identifying the correct route to the target site. Between January 2013 and March 2016, the total success rate of reaching the target site was 95.6% (347/363) at our institution. Accurate identification of the route to the target site will contribute to reduction of endoscopist's stress, a shorter scope insertion time, and the development of safe procedures for the patients.