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Description For the treatment of bile duct obstruction, a 4.5-cm submucosal tunnel is constructed from the duodenal wall to the pyloric orifice with a needle knife. The needle then is used to place the neomucosal suture approximately 5.5 cm proximal to the pyloric orifice and periampullary diverticulum. The needle is then passed through the submucosal tunnel approximately 4.5 cm, and with the needle held in the position of the current stitch, the needle is pulled through the pylorus and the periampullary diverticulum to form a zigzag suture about 3 cm in length. This completes the pyloric-preserving pyloric antrectomy. The pyloric antrectomy is performed directly under endoscopic vision. The operative field is inflated with CO2, and the duodenum is mobilized anteriorly by using a needle-knife. The duodenum is then gradually pulled away from the head of the pancreas by using a stone-basket retrieval device (SURGITA). The tunnel is expanded to the head of the pancreas and the duodenum by using the needle-knife and cannula. At this stage, a new duodenoscope is inserted into the tunnel. At the pylorus, the duodenoscope is passed to the opposite side of the pyloric orifice and periampullary diverticulum, and the new duodenoscope is passed further to the opposite side of the pyloric antrectomy. The pyloric antrectomy is completed by using the needle-knife and cannula. A submucosal tunnel is formed in the duodenum by using the needle-knife and cannula. During this procedure, the subject lies on a full-length gel-swathed table. In some cases, for example, when the ampullary orifice is small or difficult to recognize, the entrance to the bile duct may be reached by using a needle-knife or some other device. The mucosal layer is incised circumferentially with a needle-knife and an orifice for the needle-knife is opened in the duodenal wall. After the duodenal mucosa has been incised, the needle-knife is removed and a curved 0. Maryland stapling instruments or a c6a93da74d