Figure 9.

Interventions during balloon-overtube-assisted enteroscopy for endoscopic retrograde cholangiopancreatography. (a) Insertion of a guidewire through a tiny, type A hepaticojejunostomy. (b) Placement of a single 7 Fr plastic stent. (c) Multistenting using several 5 Fr (pancreatic) plastic stents. We found that pushing the smaller diameter pancreatic stents is much easier than the biliary 7 Fr plastic stents and use the ‘multi-stenting’ concept for bile duct strictures. (d) Balloon dilation of a stenotic hepaticojejunostomy. (e) The scope can be advanced into the biliary tract (i.e. direct cholangioscopy) and then selective cannulation of the branches is performed. Injection of contrast through the scope into the bile ducts. (f) Biliary sphincterotomy using a Billroth II sphincterotome in a patient with Billroth II anatomy. Notice that the direction of the bile duct is at the 5 o’clock position because the papilla is upside down.