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This is a unique clinical report of an 82year-old man with cholangitis post distal gastrectomy for treatment of ulcer disease >35 years ago, with no operative report available. The patient was referred subacutely for ERCP, which could not be performed in the primary hospital owing to unclear anatomy. First using a forward-viewing colonoscope in the left-lateral position, a jejunal limb was readily reached via the lesser curvature, with a second lumen identifiable at the opposite side, suggesting Billroth II anatomy [1]. Further advancement of the scope revealed a putative Braun’s enteroenterostomy; however, the expected third lumen was not readily identifiable. On further scrutiny, convoluted folds near the suture line came to our attention, and after mounting a cap, the apparently degenerated duodenal stump with a sharp angulation could be carefully entered with a visibly dilatory effect. The entire duodenal stump proved diffusely strictured, such that we switched to a cap-fitted gastroscope to limit perforation risks [2]. Cautious and patient push-and-pull movements with intermittent abdominal compression were needed to finally reach the papilla in a strictly tangential position (▶Fig. 1, ▶Video 1). With a view to the ensuing utterly limited scope maneuverability and stability, we again exchanged for a double-lumen gastroscope with an oblique cap attached, with the shorter axis oriented to the papilla to better align into the putative biliary axis. Next, we applied a suction-assisted cannulation approach with a straight catheter, readily enabling deep biliary access, and multiple distal bile duct stones were confirmed (▶Fig. 2, ▶Video 1). The patient underwent endoscopic papillary balloon dilation up to 8mm without endoscopic papillotomy, and partial stone extraction was performed using a wireguided basket [3]. Given an already high E-Videos

endoscopy

Mission (nearly) impossible: ERCP using an oblique cap with suction cannulation in a diffusely strictured duodenal stump after Billroth II with Braun enteroenterostomy