《Table 1 Success rates of conventional duodenoscope and forward-view endoscope in Billroth II operat

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

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DBE:Double balloon enteroscope；RYGB:Roux-en-Y gastric bypass.

Conventional duodenoscope，gastroscope，or colonoscope:The length of the afferent limb is important in selection of the endoscope.In Billroth II reconstruction with a short afferent limb，intubation is successfully achieved in most cases（62.5%-100%）with a conventional side-view duodenoscope or forward-view gastroscope with or without cap-fitting to fix the bowel wall；these should be the first-choice endoscopes（Table 1）.The route of intubation to reach the entry site into the afferent limb differs depending on the reconstruction technique，as previously described.A higher perforation rate is associated with use of a duodenoscope because of limited visualization，difficulty controlling the scope，and the need to apply more pressure to overcome looping.In contrast，while the forward-view endoscope provides better visualization，cannulation is difficult due to the tangential view to the papilla.In one study，the success rate increased from 88.6%-92.5%by use of a cap fitted at the tip of the scope[8].As shown in Table 2，Wang et al[8]and Bove et al[9]reported that the main reasons for intubation failure caused by the afferent limb are extension of the limb too far beyond the scope and the sharp angulation of the afferent limb.The success rate of gastroscopy，duodenoscopy，and colonoscopy for intubation is 84.6%，62.5%，and93.5%，respectively.Shah et al[10]reported a high success rate of deeper insertion by changing the patient’s position to the left lateral decubitus or supine position.In Billroth II reconstruction without Braun anastomosis，the papilla can be reached in>80%of cases by conventional duodenoscopy or gastroscopy.In Billroth II reconstruction with Braun anastomosis，however，the success rate ranges from 29%-90%，and the failure rate is increased[1，11].Using a conventional duodenoscope，the scope to the entry site should be at the middle entrance of the Braun anastomosis[1].For Rouxen-Y reconstruction，entering the afferent limb of the Y anastomosis is much more difficult because of the longer afferent limb length，sharper angulation，and more severe adhesion.