Can early precut reduce post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with difficult bile duct cannulation?

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is associated with a variety of adverse events(AEs).One of the most important AEs is post-ERCP pancreatitis(PEP),which is most common in cases of difficult biliary cannulation.Although the precut technique has been reported as a PEP risk factor,recent studies indicate that early precut could reduce PEP,and that precut itself is not a risk factor.AIM To evaluate the safety of the precut technique,especially in terms of PEP.METHODS We conducted a retrospective study,spanning the period from November 2011 through December 2021.It included 1556 patients,aged≥20 years,who underwent their initial ERCP attempt for biliary disease with a naïve papilla at the Kawasaki University General Medical Center.We compared the PEP risk between the early precut and the delayed precut group.RESULTS The PEP incidence rate did not significantly differ between the precut and nonprecut groups.However,the PEP incidence was significantly lower in the early precut group than the delayed precut group(3.5%vs 10.5%;P=0.02).The PEP incidence in the delayed precut group without pancreatic stent insertion(17.3%)was significantly higher compared to other cases(P<0.01).CONCLUSION Our findings indicate that early precut may reduce PEP incidence.If the precut decision is delayed,a pancreatic stent should be inserted to prevent PEP.

Acute cholangitis with Achromobacter xylosoxidans bacteremia after endoscopic retrograde cholangiopancreatography in hilar cholangiocarcinoma:A case report

BACKGROUND Achromobacter xylosoxidans is a Gram-negative opportunistic aerobe,usually causing nosocomial infections in immunocompromised patients with manifestations including bacteremia,pneumonia,and catheter-related infections.However,A.xylosoxidans have not yet been reported to cause biliary system infections.CASE SUMMARY A 72-year-old woman presented to the outpatient department of our hospital with a chief complaint of jaundice.Computed tomography of her abdomen revealed the presence of a mass of approximately 2.4 cm in the hilar portion of the common hepatic duct,consistent with hilar cholangiocarcinoma.We performed endoscopic retrograde cholangiopancreatography(ERCP)to decompress the obstructed left and right intrahepatic ducts(IHDs)and placed 10 cm and 11 cm biliary stents in the left and right IHDs,respectively.However,the day after the procedure,the patient developed post-ERCP cholangitis as the length of the right IHD stent was insufficient for proper bile drainage.The blood culture of the patient tested positive for A.xylosoxidans.Management measures included the replacement of the right IHD stent(11 cm)with a longer one(12 cm)and administering culturedirected antibiotic therapy,solving the cholangitis-related complications.After the cholangitis had resolved,the patient underwent surgery for hilar cholangiocarcinoma and survived for 912 d without recurrence.CONCLUSION A.xylosoxidans-induced biliary system infections are extremely rare.Clinical awareness of physicians and endoscopists is required as this rare pathogen might cause infection after endoscopic procedures.

Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography:A case report and review of literature

BACKGROUND Splenic injury following endoscopic retrograde cholangiopancreatography(ERCP)is a rare complication.The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989.CASE SUMMARY This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting.The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct.The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography.The patient was successfully treated with percutaneous transhepatic cholangial drainage,endoscopic pyloric stent placement,and conservative management.The causes of splenic injury following ERCP are discussed.CONCLUSION ERCP has the potential to cause splenic injury.If a patient experiences symptoms such as abdominal pain,decreased blood pressure,and altered hematology after the procedure,it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

Systemic air embolism associated with endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a key procedure for diagnosing and treating biliary and pancreatic disorders.Although effective,it carries risks,including rare but severe complications such as air embolism.CASE SUMMARY We report a case of a 58-year-old man who developed extensive air embolism during ERCP.He previously underwent a Whipple procedure and experienced a sudden drop in vital signs and loss of consciousness.Immediate intervention with hyperbaric oxygen therapy and supportive care led to gradual recovery.Imaging confirmed widespread air embolism,which resolved with continued treatment.CONCLUSION Air embolism is a rare,critical complication of ERCP,especially in patients with prior surgery such as pancreaticoduodenectomy.Early detection and prompt treatment,including hyperbaric oxygen therapy,are crucial for favorable out-comes.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians:A United States national experience

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an essential therapeutic tool for biliary and pancreatic diseases.Frail and elderly patients,especially those aged≥90 years are generally considered a higher-risk population for ERCP-related complications.AIM To investigate outcomes of ERCP in the Non-agenarian population(≥90 years)concerning Frailty.METHODS This is a cohort study using the 2018-2020 National Readmission Database.Patients aged≥90 were identified who underwent ERCP,using the international classification of diseases-10 code with clinical modification.Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail.The primary outcome was mortality,and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP.We used univariate and multivariate regression models for analysis.RESULTS A total of 9448 patients were admitted for any indications of ERCP.Frail and non-frail patients were 3445(36.46%)and 6003(63.53%)respectively.Indications for ERCP were Choledocholithiasis(74.84%),Biliary pancreatitis(9.19%),Pancreatico-biliary cancer(7.6%),Biliary stricture(4.84%),and Cholangitis(1.51%).Mortality rates were higher in frail group[adjusted odds ratio(aOR)=1.68,P=0.02].The Intra-procedural complications were insigni-ficant between the two groups which included bleeding(aOR=0.72,P=0.67),accidental punctures/lacerations(aOR=0.77,P=0.5),and mechanical ventilation rates(aOR=1.19,P=0.6).Post-ERCP complication rate was similar for bleeding(aOR=0.72,P=0.41)and post-ERCP pancreatitis(aOR=1.4,P=0.44).Frail patients had a longer length of stay(6.7 d vs 5.5 d)and higher mean total charges of hospitalization($78807 vs$71392)compared to controls(P<0.001).The 30 d all-cause readmission rates between frail and non-frail patients were similar(P=0.96).CONCLUSION There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail.Larger studies are warranted to investigate and mitigate modifiable risk factors.

Recognition and management of stent malposition in the portal vein during endoscopic retrograde cholangiopancreatography:A case report

BACKGROUND Portal vein injury is an uncommon complication of endoscopic retrograde cholangiopancreatography(ERCP),for which stent malpositioning in the portal vein is very rare and can lead to fatal events.We report a case of biliary stent migration to the portal vein and a novel method for its safe removal under the guidance of portal angiography.Moreover,we reviewed the literature and summarized reports on the identification and management of this condition.CASE SUMMARY A 59-year-old woman with pancreatic cancer presented with abdominal pain and a high fever 20 days after the placement of two plastic biliary stents under the guidance of ERCP.Blood cultures and laboratory tests revealed sepsis,which was treated with antibiotics.A contrast-enhanced computed tomography scan revealed that one of the biliary stents in the main portal vein was malpositioned.To safely remove the stent,portal angiography was performed to visualize the portal vein and to allow the management of any bleeding.The two stents were removed without obvious bleeding,and an uncovered self-expanding metal stent was placed in the common bile duct for drainage.The patient had an uneventful 6-month follow-up period,except for self-resolving portal vein thrombosis.CONCLUSION The combination of endoscopic and angiographic techniques allowed uneventful management of stent malposition in the portal vein.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

Is rectal indomethacin effective in preventing of post-endoscopic retrograde cholangiopancreatography pancreatitis?

AIM: To investigate the effectiveness of rectally administered indomethacin in the prophylaxis of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and hyperamylasaemia in a multicentre study.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis:A systematic review and meta-analysis

AIM: To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy.

Pancreatitis after endoscopic retrograde cholangiopancreatography:A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP)is a feared and potentially fatal complication that can be as high as up to 30%in high-risk patients.Pre-examination measures,during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events.Several studies have debated on the subject,however,numerous topics remain controversial,such as the effectiveness of prophylactic medications and the amylase dosage time.This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a valuable therapeutic technique for pancreatobiliary diseases,and its application in the elderly is no longer limited.However,a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.AIM To evaluate the incidence,causes,and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.METHODS A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age.One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years.The primary outcome measurements were cannulation difficulty,cannulation success rate,ERCP procedure time,and related adverse events.RESULTS There was no difference in the incidence of difficult cannulation among the two groups(32.9%vs 34.4%,P=0.765),as well as in the cannulation success rate(96.6%vs 96.8%,P=0.54).The cannulation techniques were shown to be safe and efficient in achieving successful cannulation.Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events;however,difficult cannulation cases[adjusted odds ratio(AOR)=3.478;95%confidence interval(CI):1.877-6.442;P<0.001]and patients with Charlson Comorbidity Index≥2(AOR=1.824;95%CI:0.993-3.349;P=0.045)were more likely to develop adverse events.In contrast,other factors including age≤65(AOR=3.460;95%CI:1.511-7.922;P=0.003),female gender(AOR=2.362;95%CI=1.089-5.124;P=0.030),difficult cannulation(AOR=4.527;95%CI:2.078-9.860;P<0.001),and patients with cholangitis(AOR=3.261;95%CI:1.204-8.832;P=0.020)were strongly associated with a higher rate of post-ERCP pancreatitis.CONCLUSION Advanced age has not been proved to be a risk factor for difficult cannulation,and secondary cannulation techniques can be safely and efficaciously utilized in this group.Patients with a Charlson Comorbidity Index≥2 and difficult cannulation are associated with an increased overall adverse events rate,while age≥80 years is not.

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children:A multicenter randomized controlled trial

BACKGROUND Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography(ERCP).Currently,there is no suitable treatment for post-ERCP pancreatitis(PEP)prophylaxis.Few studies have prospectively evaluated interventions to prevent PEP in children.AIM To assess the efficacy and safety of the external use of mirabilite to prevent PEP in children.METHODS This multicenter,randomized controlled clinical trial enrolled patients with chronic pancreatitis scheduled for ERCP according to eligibility criteria.Patients were randomly divided into the external use of mirabilite group(external use of mirabilite in a bag on the projected abdominal area within 30 min before ERCP)and blank group.The primary outcome was the incidence of PEP.The secondary outcomes included the severity of PEP,abdominal pain scores,levels of serum inflammatory markers[tumor necrosis factor-alpha(TNF-α)and serum interleukin-10(IL-10)],and intestinal barrier function markers[diamine oxidase(DAO),D-lactic acid,and endotoxin].Additionally,the side effects of topical mirabilite were investigated.RESULTSA total of 234 patients were enrolled,including 117 in the external use of mirabilite group and theother 117 in the blank group.The pre-procedure and procedure-related factors were notsignificantly different between the two groups.The incidence of PEP in the external use ofmirabilite group was significantly lower than that in the blank group(7.7%vs 26.5%,P<0.001).The severity of PEP decreased in the mirabilite group(P=0.023).At 24 h after the procedure,thevisual analog scale score in the external use of mirabilite group was lower than that in the blankgroup(P=0.001).Compared with those in the blank group,the TNF-αexpressions weresignificantly lower and the IL-10 expressions were significantly higher at 24 h after the procedurein the external use of mirabilite group(P=0.032 and P=0.011,respectively).There were nosignificant differences in serum DAO,D-lactic acid,and endotoxin levels before and after ERCPbetween the two groups.No adverse effects of mirabilite were observed.CONCLUSIONExternal use of mirabilite reduced the PEP occurrence.It significantly alleviated post-proceduralpain and reduced inflammatory response.Our results favor the external use of mirabilite toprevent PEP in children.

Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide.With the widespread reliance on endoscopic retrograde cholangiopancreatography(ERCP)for the management of pancreaticobiliary conditions,post-ERCP pancreatitis(PEP)has come to represent an important etiology of acute pancreatitis.Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder,findings have been heterogeneous,and considerable variation in clinical practice exists.Herein,we review the literature regarding PEP with the goal to raise awareness of this entity,discuss recent data,and present evidence-based best practices.We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.

Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP),which is the most common and serious complication of ERCP.Although the current guidelines include independent patient-and procedure-related risk factors for PEP and available PEP prophylactic measures,the synergistic effect of these risk factors on PEP should also be considered,given that patients often harbor multiple risk factors.Furthermore,a combination of prophylactic measures is often selected in clinical practice.However,established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking,and evidence on the impact of combining prophylactic measures on PEP should be discussed.Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP.ERCP indications in patients with asymptomatic common bile duct stones(CBDSs)and in those with suspected CBDSs with no imaging-based evidence of stones are controversial.Further studies are warranted to predict the synergistic effect of independent risk factors on PEP,determine the best prophylactic PEP measures,and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.

Randomized controlled trial of pancreatic stenting to prevent pancreatitis after endoscopic retrograde cholangiopancreatography

AIM:To determine the effectiveness of pancreatic duct(PD) stent placement for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography(ERCP) in high risk patients.METHODS:Authors conducted a single-blind,randomized controlled trial to evaluate the effectiveness of a pancreatic spontaneous dislodgement stent against post-ERCP pancreatitis,including rates of spontaneous dislodgement and complications.Authors defined high risk patients as having any of the following:sphincter of Oddi dysfunction,difficult cannulation,prior history of post-ERCP pancreatitis,pre-cut sphincterotomy,pancreatic ductal biopsy,pancreatic sphincterotomy,intraductal ultrasonography,or a procedure time of more than 30 min.Patients were randomized to a stent group(n = 60) or to a non-stent group(n = 60).An abdominal radiograph was obtained daily to assessspontaneous stent dislodgement.Post-ERCP pancreatitis was diagnosed according to consensus criteria.RESULTS:The mean age(± standard deviation) was 67.4 ± 13.8 years and the male:female ratio was 68:52.In the stent group,the mean age was 66 ± 13 years and the male:female ratio was 33:27,and in the non-stent group,the mean age was 68 ± 14 years and the male:female ratio was 35:25.There were no significant differences between groups with respect to age,gender,final diagnosis,or type of endoscopic intervention.The frequency of post-ERCP pancreatitis in PD stent and non-stent groups was 1.7%(1/60) and 13.3%(8/60),respectively.The severity of pancreatitis was mild in all cases.The frequency of post-ERCP pancreatitis in the stent group was significantly lower than in the non-stent group(P = 0.032,Fisher's exact test).The rate of hyperamylasemia were 30%(18/60) and 38.3%(23 of 60) in the stent and non-stent groups,respectively(P = 0.05,χ2 test).The placement of a PD stent was successful in all 60 patients.The rate of spontaneous dislodgement by the third day was 96.7%(58/60),and the median(range) time to dislodgement was 2.1(2-3) d.The rates of stent migration,hemorrhage,perforation,infection(cholangitis or cholecystitis) or other complicationss were 0%(0/60),0%(0/60),0%(0/60),0%(0/60),0%(0/60),respectively,in the stent group.Univariate analysis revealed no significant differences in high risk factors between the two groups.The pancreatic spontaneous dislodgement stent safely prevented post-ERCP pancreatitis in high risk patients.CONCLUSION:Pancreatic stent placement is a safe and effective technique to prevent post-ERCP pancreatitis.Therefore authors recommend pancreatic stent placement after ERCP in high risk patients.

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

AIM： To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography （ERCP） without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. METHODS： Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCI and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. RESULTS： The mean age of the patients was 28 years （range, 21-33 years）. The mean gestational age for the fetus was 23 wk （range, 14-34 wk）. Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. CONCLUSION： Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.

Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A meta-analysis

AIM: To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography (ERCP).

Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma

Cholangiocarcinoma(CCA) is a malignancy of the bileducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography(ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral(or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy(PDT) or radiofrequency ablation(RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCPdirected RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.

High-flow nasal oxygen availability for sedation decreases the use of general anesthesia during endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

AIM To examine whether high-flow nasal oxygen(HFNO) availability influences the use of general anesthesia(GA) in patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic ultrasound(EUS) and associated outcomes.METHODS In this retrospective study, patients were stratified into 3 eras between October 1, 2013 and June 30, 2014 based on HFNO availability for deep sedation at the time of their endoscopy. During the first and last 3-mo eras(era 1 and 3), no HFNO was available, whereas it was an option during the second 3-mo era(era 2). The primary outcome was the percent utilization of GA vs deep sedation in each period. Secondary outcomes included oxygen saturation nadir during sedation between periods, as well as procedure duration, and anesthesia-only time between periods and for GA vs sedation cases respectively.RESULTS During the study period 238 ERCP or EUS cases were identified for analysis. Statistical testing was employed and a P < 0.050 was significant unless the Bonferroni correction for multiple comparisons was used. General anesthesia use was significantly lower in era 2 compared to era 1 with the same trend between era 2 and 3(P = 0.012 and 0.045 respectively). The oxygen saturation nadir during sedation was significantly higher in era 2 compared to era 3(P < 0.001) but not between eras 1 and 2(P = 0.028) or 1 and 3(P = 0.069). The procedure time within each era was significantly longer under GA compared to deep sedation(P ≤ 0.007) as was the anesthesia-only time(P ≤ 0.001).CONCLUSION High-flow nasal oxygen availability was associated with decreased GA utilization and improved oxygenation for ERCP and EUS during sedation.

Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients

AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded. RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%. CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.