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Aim To analyze factors involved in procedural failure and to discuss responses to procedural failure by using the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) carried out using a short‐type single‐balloon enteroscope (short SBE) in patients with surgically altered gastrointestinal anatomy. Methods The study sample included patients who underwent ERCP‐related procedures using a short SBE between September 2011 and September 2018 at our hospital. Outcomes, including procedural success rate, were studied retrospectively to analyze the factors involved in procedural failure. Results Analysis included 191 procedures carried out in 121 patients. Procedural success rate was 85.9% with an adverse event rate of 8.4%. Causes of procedural failure included malignant biliary obstruction (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.19–7.25, P = 0.02), first ERCP attempt (OR: 5.32, 95% CI: 1.30–36.30, P = 0.02), and Roux‐en‐Y reconstruction (OR: 0.08, 95% CI: 0.004–0.39, P < 0.001). With regard to the response to failure, in cases of malignant biliary obstruction, reattempted short SBE‐assisted ERCP was difficult because of invasion of the small intestine or papilla. A large number of these cases required alternative treatment (10 of 15 cases, 66.7%) using percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound‐guided biliary drainage (EUS‐BD). Conclusion Endoscopic retrograde cholangiopancreatography using a short SBE is safe and effective, with malignant biliary obstruction being a specific cause of failure. Technical proficiency with different modalities, such as PTBD and EUS‐BD, is necessary to respond to failure in these cases.

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