Episode four picks up the moment standard ERCP fails, and it runs on a single habit: name the anatomic barrier and let it choose the technique. When you cannot cannulate the papilla, a dilated duct becomes an EUS target, and the finishing options rank by how much natural drainage they keep, rendezvous over choledochoduodenostomy over hepaticogastrostomy. When surgery has hidden the papilla, the question is how to restore the duodenoscope's en face view through the particular barrier, so EDGE tunnels into the bypassed stomach, balloon enteroscopy reaches a hepaticojejunostomy, and a reversed cautious approach handles Billroth two. Device design and technique are consequences of the anatomy, not lists to memorize. Topics covered EUS-guided biliary drainage and the dilated-duct target EUS-guided rendezvous Choledochoduodenostomy with a LAMS Hepaticogastrostomy and anti-migration stents Roux-en-Y gastric bypass and the EDGE procedure Balloon enteroscopy for hepaticojejunostomy Billroth two and the reversed sphincterotomy En face access as the organizing principle Key decisions Reserve EUS-guided biliary drainage for obstruction with upstream dilation, because a dilated duct is the only target you can puncture; a normal-caliber duct offers nothing to aim at. Choose EUS-guided rendezvous first whenever the papilla is reachable, since advancing a wire across the papilla for a duodenoscope preserves natural drainage and leaves no permanent fistula. Use choledochoduodenostomy with a lumen-apposing metal stent when the papilla is unreachable but the extrahepatic duct sits within a centimeter of the duodenal bulb with no intervening vessels on Doppler. Fall back to hepaticogastrostomy with a partially covered stent (covered tract segment, uncovered intraductal segment) only when neither the papilla nor the extrahepatic duct is available and a dilated left intrahepatic duct remains. Prefer the EDGE procedure over balloon enteroscopy in Roux-en-Y gastric bypass, then remove the LAMS and close the fistula at the end of biliary therapy to prevent weight regain. Reach a Roux-en-Y hepaticojejunostomy anastomosis with balloon-assisted enteroscopy, using percutaneous transhepatic cholangiography or EUS-guided hepaticogastrostomy as fallbacks. In Billroth two anatomy prefer a forward-viewing endoscope up the afferent limb given the five to eight percent perforation risk, and cut the sphincterotomy in the reversed direction, ideally a needle-knife over a placed stent. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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