A simple technique to aid intubation of the duodenoscope in the afferent limb of Billroth II gastrectomies for endoscopic retrograde cholangiopancreatography.

for the endoscopist performing endo− scopic retrograde cholangiopancreato− graphy (ERCP). The papilla appears in a reversed position in the endoscopic view, making cannulation more difficult (l" Fig. 1, 2). The initial problem usually encountered is that of finding the afferent loop and advancement of the duodeno− scope to the papillary area. Negotiating the stoma and the afferent limb is a re− cognized cause of bowel perforation [1, 2]. The use of forward−viewing endo− scopes can be sometimes helpful for ERCP in these patients [3], and perfora− tion has rarely been reported when these instruments are used. Nevertheless, some of the duodenoscope’s properties (e. g. the elevator) are sometimes necessary for biliary or pancreatic interventions in patients with Billroth II gastrectomies. A simple technique for reaching the papil− lary area in patients with this type of gas− trectomy is described here. With the patient in the prone position for ERCP, a forward−viewing, routine gastro− scope is passed into the stomach and the afferent limb is intubated to its end. A Sa− vary guide wire is passed through the working channel of the endoscope. The gastroscope is then removed, leaving the guide wire in place (l" Fig. 3). The duode− noscope is then passed alongside the Sa− vary guide wire. In the stomach, the guide wire marks the path to the afferent limb. A simple technique to aid intubation of the duodenoscope in the afferent limb of Billroth II gastrectomies for endoscopic retrograde cholangiopancreatography