title: Cap-assisted ERCP with a forward-viewing gastroscope as a rescue endoscopic intervention in patients with Billroth II anatomy.
abstract: BACKGROUND
  ERCP, especially therapeutic, is difficult in patients with Billroth II surgical reconstruction and is associated with a higher rate of complications. This has led to controversy on the choice between a forward-viewing and side-viewing endoscope for performing the procedure. A previous case series from Asia reported a high rate of success with a cap-fitted ERCP technique. To our knowledge, the utility of cap-assisted ERCP with a forward-viewing gastroscope when other techniques fail has not been reported. We describe and demonstrate a novel rescue approach using a cap-fitted, forward-viewing gastroscope in patients with Billroth II anatomy, when attempts with duodenoscopes, pediatric colonoscopes, and gastroscopes previously failed.
  
  
  METHODS
  Retrospective case series. Inclusion criteria were: (a) documented Billroth II anatomy; and (b) use of cap-assisted ERCP as a rescue intervention on the first endoscopic encounter after failed attempts to perform ERCP with a duodenoscope. Patients were excluded if they successfully underwent ERCP with a duodenoscope. One advanced endoscopist and one advanced endoscopy fellow performed all but one of the procedures.
  
  
  RESULTS
  Five cap-assisted ERCP procedures were performed in three patients with Billroth II anatomy. A wide variety of diagnostic and therapeutic endoscopic maneuvers were technically feasible and successful, including the endoscopic treatment of an afferent limb perforation caused by a duodenoscope.
  
  
  CONCLUSIONS
  Cap-assisted ERCP is a novel and underutilized technique that adds to the armamentarium of experienced therapeutic endoscopists. This approach may help ensure a successful endoscopic outcome and spare patients with Billroth II anatomy a percutaneous or surgical approach when ERCP with a duodenoscope, pediatric colonoscope or non-cap-fitted gastroscope fails.
authors: Division of Gastroenterology, Department of Medicine, Louis Stokes Cleveland VA Medical Center, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, OH, USA. constantinos.anastassiades@uhhospitals.org
authors: Constantinos P
authors: CP
authors: Anastassiades
authors: Wajeeh
authors: W
authors: Salah
authors: Eric M
authors: EM
authors: Pauli
authors: Jeffrey M
authors: JM
authors: Marks
authors: Amitabh
authors: A
authors: Chak
mesh_terms: D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D005240:Feasibility Studies; D005763:Gastroenterostomy / Q000379:methods*; D006801:Humans; D012189:Retrospective Studies