Clin Endosc.  2023 Nov;56(6):716-725. 10.5946/ce.2023.023.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a technical review

• Tanisaka Y
• Mizuide M
• Fujita A
• Shiomi R
• Shin T
• Sugimoto K
• Ryozawa S

• KMID: 2547891
• DOI: http://doi.org/10.5946/ce.2023.023

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

Keyword

Balloon enteroscopy; Endoscopic retrograde cholangiopancreatography; Single-balloon enteroscopy; Surgically altered anatomy

Figure

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  Fig. 1. Single-balloon enteroscopy (SBE). (A) A conventional SBE with a 200 cm working length and a 2.8 mm working channel in diameter. (B) A short SBE with a 152 cm working length and a 3.2 mm working channel in diameter.

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  Fig. 2. The way to advance an overtube. Scope itself should be pulled (red arrow) while advancing the overtube (pink arrow).

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  Fig. 3. Endoscopic findings. (A) A patient with Billroth II gastrectomy. The steep bending part is ordinarily the afferent limb (arrow). (B) A patient with pancreaticoduodenectomy (Child procedure). The steep bending part is ordinarily the afferent limb (arrow). (C) A patient with Roux-en-Y gastrectomy. The disruption of the transverse folds is seen, therefore the slit die of the afferent limb (arrow). (D) A hepaticojejunostomy with Roux-en-Y. There is uncertain whether it is an afferent limb or not.

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  Fig. 4. The retroflex position. (A, C) The papilla is positioned tangentially so it is difficult to perform selective biliary cannulation. (B, D) The scope is advanced while using the up-angle at the inferior duodenal angle, and adjusts to the retroflex position. Consequently, a better view of the papilla can be obtained.

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  Fig. 5. Selective biliary cannulation using the double-guidewire method. (A, B) Pancreatic duct cannulation is performed and a guidewire is placed in the pancreatic duct. (C, D) As the bile and pancreatic duct are separated well using this method, selective biliary cannulation is achieved.

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  Fig. 6. Endoscopic sphincterotomy (EST) using a dedicated sphincterotomy for patients with surgically altered anatomy. (A) The blade can be easily adjusted towards the 5 o’clock direction, which indicates the bile duct direction in patients with surgically altered anatomy. (B) Successful EST is achieved.

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  Fig. 7. Self-expandable metallic stent (SEMS) placement in patients with surgically altered anatomy. (A–C) A patient with distal malignant biliary obstruction. Covered SEMS is placed across the papilla. (D–F) A patient with hilar malignant biliary obstruction. Two uncovered SEMS (partial stent in stent method) are placed.

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