ERCP may be difficult to perform in the subset of patients with surgically altered anatomy of the upper GI tract. In expert hands, ERCP usually can be completed in patients who have undergone gastrectomy with a Billroth II anastomosis and is often successful after pancreaticoduodenectomy (Whipple operation). 1 Feitoza AB Baron TH Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part II: postsurgical anatomy with alteration of the pancreaticobiliary tree. Gastrointest Endosc. 2002; 55: 75-79 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar However, other surgical reconstructions, such as a gastrectomy or gastric bypass with Roux-en-Y hepaticojejunostomy may render endoscopic access to the biliary and pancreatic ductal orifices difficult if not impossible. MRCP will often provide sufficient visualization of ductal anatomy in such cases, and percutaneous transhepatic cholangiography (PTC) provides alternative access to the bile duct for the treatment of strictures or stones. The pancreatic ductal system, however, is more difficult to approach in such situations. In selected cases, direct pancreatography may be possible via a percutaneous 2 Opacic M Rustemovic N Pulanic R Vucelic B Frkovic M Mandic A Percutaneous pancreatography under ultrasonographic guidance. Acta Radiol. 1996; 37: 75-78 PubMed Google Scholar or EUS-guided approach. 3 Harada N Kouzu T Arima M Asano T Kikuchi T Isono K Endoscopic ultrasound-guided pancreatography: a case report. Endoscopy. 1995; 27: 612-615 Crossref PubMed Scopus (67) Google Scholar , 4 Gress F Ikenberry S Sherman S Lehman G Endoscopic ultrasound-directed pancreatography. Gastrointest Endosc. 1996; 44: 736-739 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar However, therapeutic manipulations of the pancreatic duct may require extensive surgical exploration. Two patients are described with surgically altered anatomy of the upper GI tract in whom pancreatography and endoscopic manipulation of the pancreatic duct was performed via intraoperative transjejunal ERCP. Technical aspects of this procedure are described, and its potential use is discussed.