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Aabakken et al. Mini-invasive Surg 2021;5:25 https://dx.doi.org/10.20517/2574-1225.2021.09 Page 7 of 9

[25]
In these cases, device-assisted enteroscopes are usually necessary . Access to the entero-enteric
anastomosis is usually straightforward, avoiding the passage of the stomach and ligament of Treitz. With
visual control of the anastomosis, the correct loop would be the one connected to the blind loop, usually at
an acute angle to the scope direction. Further passage will be variably complex depending on the length of
the loop and the Treitz angulation, or other fixations may be additional challenges. Also, the amount of
small bowel loops makes tip manipulation limited. Typically, the access to the papilla requires a 180 degrees
angulation at the level of the lower duodenal knee. A cap on the scope tip facilitates manipulation of the
papilla and is mostly helpful. Regardless, cannulation (usually with a straight catheter) is a challenge, also
given the lack of an instrument channel elevator on the enteroscope.

[26]
Published data confirm the technical challenges of access, as well as cannulation . Thus, percutaneous,
hybrid laparoscopic approaches, as well as endoscopic ultrasound (EUS)-assisted approaches, are being
explored, depending on the specific surgical situation . As these procedures become increasingly common
[27]
and as weight loss predisposes to the formation of gallstones, data and technical developments in this
important field are eagerly awaited.

Other anatomy - hepaticojejunostomy
The other relevant anatomical situation is a Roux-en-Y hepaticojejunostomy, either with an entero-
enterostomy, e.g., after hepatobiliary surgery complications or liver transplantations, or after Whipple
surgery. In both situations, enteroscopes are usually needed for enteric passage. However, biliary access via a
hepaticojejunostomy is usually less demanding, although identification, as well as cannulation of strictured
anastomoses may be a challenge. Again, EUS-guided alternatives are being explored, particularly for
palliative situations.

Other options
After prolonged failed attempts at biliary cannulation, the endoscopists must always consider alternatives:
call a friend or stop and try another day. Depending on the urgency of the clinical situation, the reasons for
failure and the access to more experienced colleagues are both options that must be considered. The overall
benefit of the patient must be paramount. If drainage is urgently needed, EUS-guided, as well as
percutaneous techniques must also be considered, depending on available expertise.

Conclusions
Most biliary cannulations are straightforward given the appropriate expertise. However, difficulties occur
because of specific anatomical difficulties or even because of specifics of the papillary anatomy.
Comprehensive understanding of the situation, and appropriate command of the various problem-solving
options are mandatory and must be part of the procedural armamentarium of all endoscopists performing
ERCP.

DECLARATIONS
Authors’ contributions
Developed the concept, researched the field, and prepared the manuscript: Aabakken L
Developed the concept, researched the field, and edited and supplemented the manuscript: Bhat P

Availability of data and materials
Not applicable.