IJGII Inernational Journal of Gastrointestinal Intervention

pISSN 2636-0004 eISSN 2636-0012
ESCI

Article

home All Articles View

Review Article

Int J Gastrointest Interv 2021; 10(3): 106-113

Published online July 31, 2021 https://doi.org/10.18528/ijgii210038

Copyright © International Journal of Gastrointestinal Intervention.

Recent advances of endoscopic retrograde cholangiopancreatography in surgically altered anatomy

Jin Hong Kim* and Min Jae Yang

Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea

Correspondence to:*Department of Gastroenterology, Ajou University School of Medicine, 164 WorldCup-ro, Yeongtong-gu, Suwon 16499, Korea.
E-mail address: jinhkim@ajou.ac.kr (J.H. Kim).

Received: July 6, 2021; Accepted: July 14, 2021

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) of the upper gastrointestinal tract is a more technically challenging and arduous procedure accompanied by a low success rate of reaching the target orifice and a relatively high rate of complications, compared to those with normal anatomy. Since the introduction of device-assisted enteroscopies such as balloon enteroscopy (BE) and manual spiral enteroscopy (SE) for small bowel disorders, they have also been used for ERCP in patients with SAA. The recent development of short-type BE makes ERCP in patients with SAA technically easier with high success rates and short procedural duration, and then short-type BE is considered the gold standard endoscopic procedure in these patients. Laparoscopy-assisted ERCP is another therapeutic option, especially for patients with a long excluded afferent limb of SAA. The choice of procedure for high success rates should be individualized according to patient characteristics and available physician competence. Moreover, novel motorized SE is a promising alternative procedure for the successful performance of ERCP.

Keywords: Balloon enteroscopy, Double-balloon enteroscopy, Endoscopic retrograde cholangiopancreatography, Single-balloon enteroscopy

Since its introduction in 1968, endoscopic retrograde cholangiopancreatography (ERCP) using side-viewing duodenoscope has been still widely used for the diagnostic and therapeutic procedures in biliopancreatic disorders in patients with normal gastrointestinal anatomy, although ERCP has recently evolved mainly into a therapeutic intervention due to the recent introduction of non-invasive and safer diagnostic procedures, such as endoscopic ultrasonography and magnetic resonance cholangiopancreatography. In patients with surgically altered anatomy (SAA) such as Billroth I or Billroth II anatomy with short limb, success rates of the performance of ERCP are similar to those with normal anatomy. However, ERCP is usually very challenging and time-consuming in patients with SAA, such as Roux-en-Y surgical reconstruction with hepaticojejunostomy, choledochojejunostomy, pancreaticoduodenectomy, or gastric bypass surgery, because the complexity of the long and tortuous anatomy or postoperative adhesion makes it difficult to access endoscopically.1,2 Although push enteroscope or conventional colonoscope has historically been used to access a long small bowel limb in those with SAA, it is still technically challenging to perform ERCP with limited intubation depth by intragastric or small bowel looping.3

After introducing device-assisted enteroscopy, significant advances have recently been achieved for ERCP in patients with SAA. Double-balloon enteroscopy (DBE) using a 200-cm long standard-type double-balloon enteroscope was first introduced for small bowel disorders in 2001.4 In 2003, Fujifilm Endoscopy Company commercially introduced the standard-type double-balloon enteroscope with a 2.8-mm working channel and a 200-cm working length, with standard-type single-balloon enteroscope following in 2007.5 BE-assisted ERCP using double-balloon enteroscope was first successfully performed in a patient with Roux-en-Y choledochojejunostomy reconstruction in 2005.6 However, it was still a troublesome procedure because only limited ERCP accessories are available for these 200-cm long enteroscopes.7 Since short-type balloon enteroscopy (BE) was introduced into clinical practice for ERCP performance, it has been considered the first-line policy for diagnosis and therapeutic intervention of biliopancreatic disorders in patients with problematic SAA (Table 1). Moreover, ERCP with motorized spiral enteroscopy (SE) will be another upcoming new technology for the successful performance of ERCP.8 This review discusses recent advances of ERCP using device-assisted enteroscopes in patients with SAA, except for the role of endoscopic ultrasonography-guided interventions.

Table 1 . Problematic Surgically Altered Anatomy and Choosing Initial Endoscope for Endoscopic Retrograde Cholangiopancreatography.

Operation nameGastric stateIntact papillaInitial endoscope
Afferent/efferent gastrojejunostomy
Billroth II gastrojejunostomy, short-limb/long-limbSubtotal G+Side- or forward-viewing endoscope/BE
Classic/Pylorus-preserving Whipple operationSubtotal G/IntactBE
Short-limb Roux-en-Y (< 50 cm)
Gastrectomy with Roux-en-YSubtotal G/Total G+BE
Classic/Pylorus-preserving Whipple with Roux-en-YSubtotal G/IntactBE
Biliary diversion with Roux-en-YIntactBE
Long-limb Roux-en-Y (Bariatric surgery, > 100 cm)
Roux-en-Y gastric bypassGastric pouch+BE
Biliopancreatic diversion/Duodenal switchGastric pouch+BE

Subtotal G, subtotal gastrectomy; Total G, total gastrectomy; BE, balloon enteroscope..


The advent of BE allows deep and even complete intubation of the small bowel for diagnosis and endoscopic intervention in patients with small bowel disorders. Moreover, its indications have been extended to ERCP in those with SAA, where it was impossible to complete the procedure using conventional forward-viewing or side-viewing endoscopes. The balloon enteroscope is advanced by holding and shortening the small bowel long-limbs with the inflated balloon(s). When it makes a loop during insertion, the small bowel is fixed using the inflated balloon(s) and shortened by withdrawing the BE. There are four types of balloon enteroscopes; standard-type double-balloon enteroscope, short-type double-balloon enteroscope, standard-type single-balloon enteroscope, and short-type single-balloon enteroscope. A single-balloon enteroscope has a balloon attached to the tip end of the over-tube, while a double-balloon enteroscope has two balloons attached to each tip end of the endoscope and the over-tube. Table 2 shows the specifications of balloon enteroscopes currently available for ERCP in those with SAA. A novel standard-type single balloon enteroscope (SIF-H190; Olympus Optical Co., Tokyo, Japan) was launched in Japan and Europe early in 2021. It has a wider working channel with a diameter of 3.2 mm to improve endo-therapeutic instrumental maneuverability than that of the existing enteroscope with a diameter of 2.8 mm (SIF Q260; Olympus Optical Co.), while maintaining an outer diameter of enteroscope equivalent to the existing one. After its introduction, all four types of balloon enteroscopes finally had the same wide working channel with a diameter of 3.2 mm. It has the same newly developed technologies as short-type single-balloon enteroscope (SIF-H290S; Olympus Optical Co.), such as a passive bending and high force transmission to facilitate smoother passage and sharp and clear high-definition imaging for better observation. Short-type double-balloon enteroscope (EI-580BT; Fujifilm Endoscopy, Tokyo, Japan) has another newly developed technology of an adaptive bending part and advanced force transmission, similar to the passive bending and high force transmission of single-balloon enteroscopes. The endoscopic accessories from the working channel port appear in a 5:30 o’clock direction on the endoscopic image for DBE, while it shows in an 8 o’clock direction for single-balloon enteroscopy (SBE).

Table 2 . Specifications of Balloon Enteroscopes Currently Available.

Scope typeFujifilmOlympus
Standard typeShort typeStandard typeShort type
EN-580TEI-580BTSIF-Q260SIF-H190SIF-H290S
Release date (yr)20132016200720212016
Direction of viewForwardForwardForwardForwardForward
Field of view (degree)140140140140140
Distal outer diameter (mm)9.49.49.29.29.2
Total length (mm)2,3001,8202,3452,2801,840
Working length (mm)2,0001,5502,0002,0001,520
Working channel (mm)3.23.22.83.23.2
Adaptive bending partNoYesNoNoNo
Advanced force transmissionNoYesNoNoNo
Passive bending partNoNoNoYesYes
High force transmissionNoNoNoYesYes


A short-type balloon enteroscope with 152 cm in length overcomes some of the problems associated with manipulating a long instrument of standard-type with 200 cm in length and allows most ERCP accessories with standard length to be used and facilitated treatment procedures.9 The ability of the short-type BE to reach the papilla of Vater or bilioenteric anastomosis was comparable with and even slightly superior with that of the standard-type BE.10 Comparing DBE and SBE for ERCP in patients with Roux-en-Y reconstruction, both techniques were equally competent with high success rates and acceptable complication rates.11 When the target site cannot be reached during short-type BE in patients with long-limb Roux-en-Y reconstruction because of its short length, standard-type BE should be considered as the next step before performing more invasive percutaneous or surgical alternatives.12 The most severe and problematic complication of BE-assisted ERCP was a perforation, which can occur in five different types, including intestinal perforation by scope tip, scope body, or tight tension during scope manipulation, peri-papillary perforation by device insertion, and bile duct perforation during balloon dilation.12

Short-type double balloon-assisted ERCP

A double-balloon enteroscope has two balloons; one is attached to the tip end of the endoscope, and the other is attacked to the tip end of the over-tube. Since a short-type double-balloon enteroscope (EC-450BI5; Fujifilm Endoscopy) was first introduced in 2005, with a 2.8-mm working channel and a 152-cm working length, short-type double-balloon enteroscope (EI-580BT; Fujifilm Endoscopy) with a 155-cm working length and a 3.2-mm working channel has newly developed technology of an adaptive bending part and advanced force transmission tract.13 The adaptive bending system is designed to control intestinal tract angulations with a flexible soft part at the end of the enteroscope. It allows the enteroscope to bend along the angulation of the intestinal tract and helps the enteroscope return to its straight shape after passing through angulation. The advanced force transmission is designed to transmit the pushing, pulling, and rotating movements from the handle to the distal end of the enteroscope, thus providing enhanced maneuverability of the double-balloon enteroscope.

The patient group performing short-type DBE had a shorter insertion time required to reach the target site than the patient group performing standard-type DBE (10 min vs 14 min; P < 0.01). The success rate of pancreaticobiliary interventions in the short-type DBE group was as high as that in the standard-type DBE group (92% vs 89%; P = 0.35). A short-type DBE allows faster insertion to the target site for pancreaticobiliary intervention in patients with SAA.14 Table 3 shows the outcomes of short-type DBE-assisted ERCP in patients with SAA.9,10,1228 The success rates of reaching the target site, biliary cannulation, and therapeutic procedure in short-type DBE-assisted ERCP were 94.8%, 95.6%, and 94.5%, respectively, from these pooled data. On the other hand, the latest systematic review and meta-analysis reported that the success rates of reaching the target site, biliary cannulation, and therapeutic procedure in both short-type and standard-type DBE-assisted ERCP were 90%, 94%, and 93%, respectively.29 Complications occurred in 6.8% during short-type DBE-assisted ERCP (Table 4). Perforation or emphysema occurred in 28 out of 2016 cases (1.4%). Pancreatitis occurred 1.7%. Other minor complications included cholangitis, bleeding, mucosal laceration, bile leakage, biliary damage, aspiration pneumonia, and ischemic liver graft.

Table 3 . Outcomes of Short-Type Double-Balloon Enteroscopy-Assisted ERCP in Patients with Surgically Altered Anatomy.

Author (year)No. of patients
(procedures)
Altered anatomy (n)Enteroscopy success,
% (n)
Selective cannulation
success, % (n)
Therapeutic success,
% (n)
Shimatani et al (2009)1068 (103)Overall (103)
B-II (17)
R-Y TG (36)
PD (15)
97.1 (100/103)
100 (22/22)
94.5 (52/55)
100 (26/26)
98.0 (98/100)
100 (22/22)
96.2 (50/52)
100 (26/26)
100 (98/98)
100 (22/22)
100 (50/50)
100 (26/26)
Tsujino et al (2010)156 (12)Overall (12)
HJ (7)
R-Y (3)
PD (2)
100 (12/12)100 (12/12)100 (12/12)
Cho et al (2011)920 (29)Overall (20)
B-II (6)
R-Y (13)
PD (1)
86.2 (25/29)96.0 (24/25)100 (24/24)
Osoegawa et al (2012)1628 (47)Overall (47)
B-II (19)
R-Y (25)
PD (3)
95.7 (45/47)
94.7 (18/19)
96.0 (24/25)
100 (3/3)
88.9 (40/45)
88.9 (16/18)
87.5 (21/24)
100 (3/3)
100 (40/40)
100 (16/16)
100 (21/21)
100 (3/3)
Siddiqui et al (2013)1779 (79)Overall (79)
B-II (3)
R-Y (53)
HJ (3)
PD (20)
89.9 (71/79)
100 (3/3)
86.8 (46/53)
100 (3/3)
95.0 (19/20)
90.1 (64/71)
100 (3/3)
91.3 (42/46)
100 (3/3)
84.2 (16/19)
100 (64/64)
Choi et al (2013)1828 (32)RYGB (32)78.1 (25/32)80.0 (20/25)90.0 (18/20)
Katanuma and Isayama (2014)12N/A (281)Overall (281)
B-II (23)
R-Y (68)
PD (92)
HJ (72)
LT (18)
Interposition (8)
94.0 (264/281)
100 (23/23)
97.1 (66/68)
95.7 (88/92)
87.5 (63/72)
88.9 (16/18)
100 (8/8)
N/AN/A
Tsutsumi et al (2015)2772 (72)Overall (72)
PD (41)
PPPD (20)
SSPPD (10)
98.6 (71/72)100 (71/71)100 (71/71)
Sakakihara et al (2015)2244 (44)Overall (44)
R-Y (17)
PD (27)
86.4 (38/44)94.7 (36/38)100 (36/36)
Shimatani et al (2016)24311(311)Overall (311)
B-II (26)
R-Y (203)
PD (44)
PPPD (31)
Others (7)
97.7 (304/311)
96.2 (25/26)
97.0 (197/203)
100 (44/44)
100 (31/31)
100 (7/7)
96.4 (293/304)
100 (25/25)
97.0 (191/197)
97.7 (43/44)
90.3 (28/31)
85.7 (6/7)
97.9 (277/283)
100 (24/24)
96.8 (179/185)
100 (42/42)
100 (26/26)
100 (6/6)
Tomoda et al (2016)2520 (20)HJ (20)85.0 (17/20)82.4 (14/17)78.6 (11/14)
Tsou et al (2016)2647 (73)R-Y (47)76.6 (36/47)94.9 (37/39)*100 (37/37)*
Shimatani et al (2017)13100 (112)Overall (112)
B-II (11)
R-Y (67)
PD (17)
PPPD (14)
Others (3)
99.1 (111/112)
100 (11/11)
98.5 (66/67)
100 (17/17)
100 (14/14)
100 (3/3)
98.2 (109/111)
100 (11/11)
98.5 (65/66)
100 (17/17)
92.9 (13/14)
100 (3/3)
100 (109/109)
100 (11/11)
100 (65/65)
100 (17/17)
100 (13/13)
100 (3/3)
Matsumoto et al (2018)2011 (11)Overall
R-Y (7)
PPPD (4)
100 (11/11)
100 (7/7)
100 (4/4)
N/A63.6 (7/11)
42.9 (3/7)
100 (4/4)
Mizukawa et al (2018)2146 (46)PD (46)100 (46/46)100 (46/46)100 (46/46)
Yamada et al (2019)14N/A (163)Overall (163)
B-II (16)
R-Y (107))
HJ (9)
PD (29)
100 (163/163)95.7 (156/163)96.2 (150/156)
Uchida et al (2020)28319 (805)Overall (805)
B-II (43)
R-Y (390)
PPPD (60)
SSPPD (312)
94.3 (759/805)
97.7 (42/43)
91.0 (355/390)
96.7 (58/60)
97.4 (304/312)
N/A90.7 (730/805)
93.0 (40/43)
87.2 (340/390)
95.0 (57/60)
93.9 (293/312)
Sato et al (2020)23102 (102)Overall (102)
B-II (22)
R-Y (80)
N/AN/A89.2 (91/102)

ERCP, endoscopic retrograde cholangiopancreatography; B-II, Billroth II; R-Y, Reux-en-Y; TG, total gastrectomy; PD, pancreaticoduodenectomy; HJ, hepaticojejunostomy; RYGB, Reux-en-Y gastric bypass; LT, liver transplantation; PPPD, pyloric preserving pancreaticoduodenectomy; SSPPD, subtotal stomach-reserving pancreaticoduodenectomy; N/A, not available..

*Success rate combined short-type double-balloon enteroscopy and standard-type double-balloon enteroscopy..



Table 4 . Complications of Short-Type Double-Balloon Enteroscopy-Assisted ERCP in Patients with Surgically Altered Anatomy.

Author (year)Complications, % (n)Perforation or emphysema (n)Pancreatitis (n)Others (n)
Shimatani et al (2009)104.9 (5/103)Intestinal perforation (1)
Retroperitoneal perforation (1)
Post-EST perforation (1)
Retroperitoneal emphysema (1)
Subcutaneous emphysema with
pneumothorax (1)
00
Tsujino et al (2010)1516.6 (2/12)Retroperitoneal air (1)0Cholangitis (1)
Cho et al (2011)90 (0/29)000
Osoegawa et al (2012)163.6 (1/28)Intestinal perforation (1)00
Siddiqui et al (2013)178.9 (7/79)0Mild (3)Abdominal pain (3)
Post-procedural bleeding (1)
Choi et al (2013)183.1 (1/32)0Moderate (1)0
Katanuma and Isayama (2014)12N/AN/AN/AN/A
Tsutsumi et al (2015)272.8 (2/72)00Cholangitis (2)
Sakakihara et al (2015)2215.9 (7/44)00Cholangitis (7)
Shimatani et al (2016)2410.6 (33/311)Obvious perforation (1)
Microperforation (6)
11Mucosal laceration (1)
Biliary damage (4)
Cholangitis (8)
Aspiration pneumonia (2)
Tomoda et al (2016)2510.0 (2/20)00Ischemic liver graft (1)
Tsou et al (2016)264.3 (2/47)Intestinal perforation (1)0Cholangitis (1)
Shimatani et al (2017)132.7 (3/112)00Mucosal laceration (3)
Matsumoto et al (2018)200 (0/11)000
Mizukawa et al (2018)216.5 (3/46)00Cholangitis (3)
Yamada et al (2019)144.3 (7/163)Retroperitoneal emphysema (1)60
Uchida et al (2020)285.4 (44/805)Intestinal perforation (6)14Cholangitis (20)
Others (4)
Sato et al (2020)2317.6 (18/102)Intra-abdominal and/or retroperitoneal air (6)0Cholangitis (10)
Bile leakage (1)
Bleeding (1)

ERCP, endoscopic retrograde cholangiopancreatography; EST, endoscopic sphincterotomy; N/A, not available..



Short-type single balloon-assisted ERCP

A single-balloon enteroscope has one balloon attached to the tip of the over-tube without a balloon attached to the tip end of the endoscope. A short-type double-balloon enteroscope (SIF-H20S; Olympus Optical Co.) was launched in 2016 with a 152-cm working length and a 3.2-mm working channel, enabling nearly all devices used to perform conventional ERCP. It has sharp and clear high-definition imaging for better observation and also has newly developed passive bending and high force transmission technology to facilitate smoother passage, similar to a colonoscope. The use of a SBE with passive bending and high force transmission functions may increase the success rate of reaching the blind end. Yamauchi et al30 reported that short-type SBE was useful for ERCP in patients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.

Table 5 shows the outcomes of short-type SBE-assisted ERCP in patients with SAA.19,3036 The success rates of reaching the target site, biliary cannulation, and therapeutic procedure in short-type SBE-assisted ERCP were 91.8%, 89.9%, and 91.1%, respectively, from these pooled data. Causes of procedural failure included malignant biliary obstruction, first ERCP attempt, and Roux-en-Y reconstruction,32 and multivariate analyses indicated that pancreatic indication, first ERCP attempt, and no transparent hood were potential risk factors for procedural failure.33 Complications occurred in 6.8% during short-type SBE-assisted ERCP (Table 6). Perforation or emphysema occurred in 9 out of 636 cases (1.4%). Pancreatitis occurred 2.8%. Other minor complications included cholangitis, Cholecystitis, bleeding of the papilla, mucosal laceration, and hematoma.

Table 5 . Outcomes of Short-Type Single-Balloon Enteroscopy-Assisted ERCP in Patients with Surgically Altered Anatomy.

Author
(year)
No. of patients (procedures)Altered anatomy (n)Enteroscopy success,
% (n)
Selective cannulation
success, % (n)
Therapeutic success,
% (n)
Yamauchi et al (2013)3622 (31)Overall (31)
B-II (8)
R-Y gastrectomy (21)
R-Y HJ (2)
90.5 (28/31)
87.5 (7/8)
90.5 (19/21)
100 (2/2)
89.3 (25/28)
85.7 (6/7)
89.5 (17/19)
100 (2/2)
95.7 (22/23)
100 (5/5)
93.8 (15/16)
100 (2/2)
Obana et al (2013)348 (12)R-Y gastrectomy (8)87.5 (7/8)71.4 (5/7)71.4 (5/7)
Iwai et al (2014)31N/A (62)Overall (62)
B-II (10)
R-Y (52)
91.9 (57/62)
90.0 (9/10)
92.3 (48/52)
87.7 (50/57)
88.9 (8/9)
87.5 (42/48)
94.1 (48/51)
100 (8/8)
93.0 (40/43)
Shimatani et al (2014)3526 (26)Overall (26)
B-II (3)
R-Y gastrectomy (4)
R-Y HJ (8)
PD (4)
PPPD (5)
Other (2)
92.3 (24/26)
100 (3/3)
100 (4/4)
75.0 (6/8)
100 (4/4)
100 (5/5)
100 (2/2)
91.7 (22/24)
100 (3/3)
75.0 (3/4)
100 (6/6)
100 (4/4)
100 (5/5)
50.0 (1/2)
100 (22/22)
100 (3/3)
100 (3/3)
100 (6/6)
100 (4/4)
100 (5/5)
100 (1/1)
Kawamura et al (2015)1918 (27)Overall (27)
B-II (2)
R-Y gastrectomy (15)
R-Y CJ (10)
88.9 (24/27)
100 (2/2)
86.7 (13/15)
90.0 (9/10)
83.3 (20/24)
50.0 (1/2)
76.9 (10/13)
100 (9/9)
95.0 (19/20)
100 (1/1)
90.0 (9/10)
100 (9/9)
Yamauchi et al (2015)3062 (84)Overall (84)
R-Y gastrectomy (63)
R-Y HJ (21)
90.5 (76/84)89.5 (68/76)95.6 (65/68)
Yane et al (2017)33117 (203)Overall (203)
B-II (20)
R-Y gastrectomy (45)
R-Y HJ (59)
PD (79)
92.6 (188/203)
100 (20/20)
95.6 (43/45)
81.4 (48/59)
97.5 (77/79)
N/A81.8 (166/203)
95.0 (19/20)
88.9 (40/45)
79.7 (47/59)
75.9 (60/79)
Tanisaka et al (2019)32121 (191)Overall (191)
B-II (31)
R-Y gastrectomy (87)
R-Y HJ (34)
PD (39)
94.8 (181/191)
100 (31/31)
93.1 (81/87)
88.2 (30/34)
100 (39/39)
92.3 (167/181)
100 (31/31)
85.2 (69/81)
96.7 (29/30)
97.4 (38/39)
98.2 (164/167)
100 (31/31)
95.7 (66/69)
100 (29/29)
100 (38/38)

ERCP, endoscopic retrograde cholangiopancreatography; B-II, Billroth II; R-Y, Reux-en-Y; HJ, hepaticojejunostomy; PD, pancreaticoduodenectomy; PPPD, pyloric preserving pancreaticoduodenectomy; CJ, choledochojejunostomy; N/A, not available..



Table 6 . Complications of Short-Type Single-Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy.

Author (year)Complications, % (n)Perforation or emphysema (n)Pancreatitis (n)Others (n)
Yamauchi et al (2013)3612.9 (4/31)*Intestinal perforation (1)2Bleeding of papilla (1)
Obana et al (2013)340 (0/12)000
Iwai et al (2014)319.7 (6/62)Intestinal perforation (2)3Bleeding of papilla (1)
Shimatani et al (2014)353.8 (1/26)00Hematoma (1)
Kawamura et al (2015)190 (0/27)000
Yamauchi et al (2015)304.8 (4/84)*Intestinal perforation (2)Mild (2)0
Yane et al (2017)335.9 (12/203)Intestinal perforation (2)
Guidewire perforation (1)
3Cholangitis (4)
Cholecystitis (1)
Mucosal laceration (1)
Tanisaka et al (2019)328.4 (16/191)Intestinal perforation (1)8Cholangitis (6)
Mucosal laceration (1)

*Hyperamylasenemia was excluded from major complications..


SE is a technique that was first introduced in 2006 by Akerman et al37 for deep small bowel intubation. SE has recently been used for deep enteroscopy in patients with many normal and altered anatomy, including ERCP procedures. Diagnostic and therapeutic yields were similar with SBE-assisted ERCP and SE-assisted ERCP in patients with Roux-en-Y anatomy with no significant difference in procedure time or complication rates.38 In a multicenter retrospective study on device-assisted enteroscopy, ERCP success rates were similar among SBE, DBE, and SE with an overall ERCP success rate of 63% in patients with both Roux-en-Y gastric bypass and other long-limb surgical bypasses.39 A recent large single-center study reported that SE-assisted ERCP in 35 patients with bariatric-long-limb Roux-en-Y reconstruction is safe and effective with overall success rate of 86 %.40

Motorized SE is another upcoming new technology, namely ‘self-propelling’ enteroscopy, available from 2015.41 A novel reusable PSF-1 PowerSpiral enteroscope (Olympus Medical Systems, Tokyo, Japan) has an integrated electric motor for rotating a disposable short spiral overtube mounted on a rotation coupler located in the distal quarter of the insertion tube.42 It has a working length of 168 cm, an outer diameter of 11.3 mm, and a working channel diameter of 3.2 mm. Disposable atraumatic spiral overtube has a total length of 240 mm, an outer diameter of 18.1 mm, an outer diameter of soft spiral fins of 31.1 mm. Recent two prospective clinical studies in patients with suspected small bowel disorders showed that complete enteroscopy is feasible with motorized SE, either from antegrade alone or bidirectionally, with high success rates and short procedural duration.43 These results justify further evaluation for clinical application and safety of motorized SE in a large-scale prospective multicenter study.

In patients with biliopancreatic diversion, the long efferent and afferent limbs prevent any change of performing traditional ERCP. Moreover, It is usually impossible to perform traditional ERCP very similar to the biliopancreatic diversion surgery in duodenal switch procedure.44 Since the introduction of BE, it becomes the gold standard for performing ERCP in altered anatomy, especially with a very long limb as in Reux-en-Y gastric bypass and Roux-en-Y reconstruction. When BE-assisted ERCP failed in these patients, many alternative endoscopic and surgical techniques can be adopted as the next step for successful biliopancreatic diagnosis and intervention, such as endoscopic ultrasonography-guided ERCP, endoscopic gastropexy or gastrostomy ERCP, and laparoscopy-assisted ERCP.45 Laparoscopy-assisted ERCP is performed by laparoscopically creating a gastrostomy through which a standard duodenoscope can be advanced into the excluded stomach and duodenum.46 Studies about Laparoscopy-assisted ERCP reported that this method had high success rates with a higher overall complication rate than standard ERCP due to the laparoscopic approach.46,47 In patients with Reux-en-Y gastric bypass, laparoscopy-assisted ERCP and BE-assisted ERCP had high success rates of 87.2% and 72.5%, respectively, if performing in experienced hands.48 Therefore, the choice of procedure should be individualized according to the patient’s characteristics and the expertise of endoscopists.

Diagnostic and therapeutic options for ERCP in patients with SAA have traditionally been limited and frustrating for endoscopists. Recently, device-assisted enteroscopy, including BE-, SE-, and laparoscopy-assisted ERCP, have improved the diagnostic and therapeutic yield compared with earlier methods. However, each of the currently available methods has limitations. Motorized SE could be another upcoming new ERCP technology in patients with SAA. The success of ERCP in terms of reaching the target site, biliary cannulation, and procedural success in patients with SAA is mainly related to the length and mobility of the bowel needing to be traversed and the expertise of endoscopists. Despite these significant advances in device-assisted ERCP, there still exists considerable room for improvement, and the development of new, rapid, safe, and practical techniques is needed for ERCP in patients with SAA.

This research was supported by the Ministry of Science and ICT (MSIT), Korea, under the Information Technology Research Center (ITRC) support program (IITP-2021-2020-0-01461) supervised by the Institute for Information & Communications Technology Planning & Evaluation (IITP).


No potential conflict of interest relevant to this article was reported.

  1. Moreels TG. ERCP in the patient with surgically altered anatomy. Curr Gastroenterol Rep. 2013;15:343.
    Pubmed CrossRef
  2. Moreels TG. Endoscopic retrograde cholangiopancreatography in patients with altered anatomy: how to deal with the challenges? World J Gastrointest Endosc. 2014;6:345-51.
    Pubmed KoreaMed CrossRef
  3. Moreels TG. Altered anatomy: enteroscopy and ERCP procedure. Best Pract Res Clin Gastroenterol. 2012;26:347-57.
    Pubmed CrossRef
  4. Yamamoto H, Sekine Y, Sato Y, Higashizawa T, Miyata T, Iino S, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc. 2001;53:216-20.
    Pubmed CrossRef
  5. Kawamura T, Yasuda K, Tanaka K, Uno K, Ueda M, Sanada K, et al. Clinical evaluation of a newly developed single-balloon enteroscope. Gastrointest Endosc. 2008;68:1112-6.
    Pubmed CrossRef
  6. Haruta H, Yamamoto H, Mizuta K, Kita Y, Uno T, Egami S, et al. A case of successful enteroscopic balloon dilation for late anastomotic stricture of choledochojejunostomy after living donor liver transplantation. Liver Transpl. 2005;11:1608-10.
    Pubmed CrossRef
  7. Gómez V, Petersen BT. Endoscopic retrograde cholangiopancreatography in surgically altered anatomy. Gastrointest Endosc Clin N Am. 2015;25:631-56.
    Pubmed CrossRef
  8. Tanisaka Y, Mizuide M, Fujita A, Ogawa T, Suzuki M, Katsuda H, et al. Recent advances of interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound for patients with surgically altered anatomy. J Clin Med. 2021;10:1624.
    Pubmed KoreaMed CrossRef
  9. Cho S, Kamalaporn P, Kandel G, Kortan P, Marcon N, May G. 'Short' double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract. Can J Gastroenterol. 2011;25:615-9.
    Pubmed KoreaMed CrossRef
  10. Shimatani M, Matsushita M, Takaoka M, Koyabu M, Ikeura T, Kato K, et al. Effective "short" double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy. 2009;41:849-54.
    Pubmed CrossRef
  11. De Koning M, Moreels TG. Comparison of double-balloon and single-balloon enteroscope for therapeutic endoscopic retrograde cholangiography after Roux-en-Y small bowel surgery. BMC Gastroenterol. 2016;16:98.
    Pubmed KoreaMed CrossRef
  12. Katanuma A, Isayama H. Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy in Japan: questionnaire survey and important discussion points at Endoscopic Forum Japan 2013. Dig Endosc. 2014;26(Suppl 2):109-15.
    Pubmed CrossRef
  13. Shimatani M, Takaoka M, Okazaki K. Utility of endoscopic therapy using a double balloon endoscope combined with a long-type ultra-slim endoscope in postoperative patient allergic to contrast media (with video). Dig Endosc. 2017;29:124-5.
    Pubmed CrossRef
  14. Yamada A, Kogure H, Nakai Y, Takahara N, Mizuno S, Tada M, et al. Performance of a new short-type double-balloon endoscope with advanced force transmission and adaptive bending for pancreaticobiliary intervention in patients with surgically altered anatomy: a propensity-matched analysis. Dig Endosc. 2019;31:86-93.
    Pubmed CrossRef
  15. Tsujino T, Yamada A, Isayama H, Kogure H, Sasahira N, Hirano K, et al. Experiences of biliary interventions using short double-balloon enteroscopy in patients with Roux-en-Y anastomosis or hepaticojejunostomy. Dig Endosc. 2010;22:211-6.
    Pubmed CrossRef
  16. Osoegawa T, Motomura Y, Akahoshi K, Higuchi N, Tanaka Y, Hisano T, et al. Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography. World J Gastroenterol. 2012;18:6843-9.
    Pubmed KoreaMed CrossRef
  17. Siddiqui AA, Chaaya A, Shelton C, Marmion J, Kowalski TE, Loren DE, et al. Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study. Dig Dis Sci. 2013;58:858-64.
    Pubmed CrossRef
  18. Choi EK, Chiorean MV, Coté GA, El Hajj II, Ballard D, Fogel EL, et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc. 2013;27:2894-9.
    Pubmed CrossRef
  19. Kawamura T, Uno K, Suzuki A, Mandai K, Nakase K, Tanaka K, et al. Clinical usefulness of a short-type, prototype single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy: preliminary experiences. Dig Endosc. 2015;27:82-6.
    Pubmed CrossRef
  20. Matsumoto K, Tsutsumi K, Kato H, Horiguchi S, Saragai Y, Takada S, et al. Efficacy of endoscopic treatment using double-balloon enteroscopy for postoperative bile leakage in patients with hepaticojejunostomy. Endosc Int Open. 2018;6:E211-6.
    Pubmed KoreaMed CrossRef
  21. Mizukawa S, Tsutsumi K, Kato H, Muro S, Akimoto Y, Uchida D, et al. Endoscopic balloon dilatation for benign hepaticojejunostomy anastomotic stricture using short double-balloon enteroscopy in patients with a prior Whipple's procedure: a retrospective study. BMC Gastroenterol. 2018;18:14.
    Pubmed KoreaMed CrossRef
  22. Sakakihara I, Kato H, Muro S, Noma Y, Yamamoto N, Harada R, et al. Double-balloon enteroscopy for choledochojejunal anastomotic stenosis after hepato-biliary-pancreatic operation. Dig Endosc. 2015;27:146-54.
    Pubmed CrossRef
  23. Sato T, Kogure H, Nakai Y, Ishigaki K, Hakuta R, Saito K, et al. Double-balloon endoscopy-assisted treatment of hepaticojejunostomy anastomotic strictures and predictive factors for treatment success. Surg Endosc. 2020;34:1612-20.
    Pubmed CrossRef
  24. Shimatani M, Hatanaka H, Kogure H, Tsutsumi K, Kawashima H, Hanada K, et al. Diagnostic and therapeutic endoscopic retrograde cholangiography using a short-type double-balloon endoscope in patients with altered gastrointestinal anatomy: a multicenter prospective study in Japan. Am J Gastroenterol. 2016;111:1750-8.
    Pubmed CrossRef
  25. Tomoda T, Tsutsumi K, Kato H, Mizukawa S, Yabe S, Akimoto Y, et al. Outcomes of management for biliary stricture after living donor liver transplantation with hepaticojejunostomy using short-type double-balloon enteroscopy. Surg Endosc. 2016;30:5338-44.
    Pubmed CrossRef
  26. Tsou YK, Lee MS, Chen KF, Lin CH, Sung KF, Wu CC. Double-balloon enteroscopy-assisted endoscopic retrograde cholangiography for Roux-en-Y reconstruction patients with papilla of Vater or bilioenteric anastomosis. Scand J Gastroenterol. 2016;51:95-102.
    Pubmed CrossRef
  27. Tsutsumi K, Kato H, Muro S, Yamamoto N, Noma Y, Horiguchi S, et al. ERCP using a short double-balloon enteroscope in patients with prior pancreatoduodenectomy: higher maneuverability supplied by the efferent-limb route. Surg Endosc. 2015;29:1944-51.
    Pubmed CrossRef
  28. Uchida D, Tsutsumi K, Kato H, Matsumi A, Saragai Y, Tomoda T, et al. Potential factors affecting results of short-type double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography. Dig Dis Sci. 2020;65:1460-70.
    Pubmed CrossRef
  29. Anvari S, Lee Y, Patro N, Soon MS, Doumouras AG, Hong D. Double-balloon enteroscopy for diagnostic and therapeutic ERCP in patients with surgically altered gastrointestinal anatomy: a systematic review and meta-analysis. Surg Endosc. 2021;35:18-36.
    Pubmed CrossRef
  30. Yamauchi H, Kida M, Okuwaki K, Miyazawa S, Iwai T, Tokunaga S, et al. Passive-bending, short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients. World J Gastroenterol. 2015;21:1546-53.
    Pubmed KoreaMed CrossRef
  31. Iwai T, Kida M, Yamauchi H, Imaizumi H, Koizumi W. Short-type and conventional single-balloon enteroscopes for endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: single-center experience. Dig Endosc. 2014;26(Suppl 2):156-63.
    Pubmed CrossRef
  32. Tanisaka Y, Ryozawa S, Mizuide M, Harada M, Fujita A, Ogawa T, et al. Analysis of the factors involved in procedural failure: Endoscopic retrograde cholangiopancreatography using a short-type single-balloon enteroscope for patients with surgically altered gastrointestinal anatomy. Dig Endosc. 2019;31:682-9.
    Pubmed CrossRef
  33. Yane K, Katanuma A, Maguchi H, Takahashi K, Kin T, Ikarashi S, et al. Short-type single-balloon enteroscope-assisted ERCP in postsurgical altered anatomy: potential factors affecting procedural failure. Endoscopy. 2017;49:69-74.
    Pubmed CrossRef
  34. Obana T, Fujita N, Ito K, Noda Y, Kobayashi G, Horaguchi J, et al. Therapeutic endoscopic retrograde cholangiography using a single-balloon enteroscope in patients with Roux-en-Y anastomosis. Dig Endosc. 2013;25:601-7.
    Pubmed CrossRef
  35. Shimatani M, Takaoka M, Ikeura T, Mitsuyama T, Okazaki K. Evaluation of endoscopic retrograde cholangiopancreatography using a newly developed short-type single-balloon endoscope in patients with altered gastrointestinal anatomy. Dig Endosc. 2014;26(Suppl 2):147-55.
    Pubmed CrossRef
  36. Yamauchi H, Kida M, Okuwaki K, Miyazawa S, Iwai T, Takezawa M, et al. Short-type single balloon enteroscope for endoscopic retrograde cholangiopancreatography with altered gastrointestinal anatomy. World J Gastroenterol. 2013;19:1728-35.
    Pubmed KoreaMed CrossRef
  37. Akerman PA, Agrawal D, Chen W, Cantero D, Avila J, Pangtay J. Spiral enteroscopy: a novel method of enteroscopy by using the Endo-Ease Discovery SB overtube and a pediatric colonoscope. Gastrointest Endosc. 2009;69:327-32.
    Pubmed CrossRef
  38. Lennon AM, Kapoor S, Khashab M, Corless E, Amateau S, Dunbar K, et al. Spiral assisted ERCP is equivalent to single balloon assisted ERCP in patients with Roux-en-Y anatomy. Dig Dis Sci. 2012;57:1391-8.
    Pubmed CrossRef
  39. Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA, et al. A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77:593-600.
    Pubmed CrossRef
  40. Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN. Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc. 2018;87:1241-7.
    Pubmed CrossRef
  41. Neuhaus H, Beyna T, Schneider M, Devière J. Novel motorized spiral enteroscopy: first clinical case. VideoGIE. 2016;1:32-3.
    Pubmed KoreaMed CrossRef
  42. Beyna T, Schneider M, Höllerich J, Neuhaus H. Motorized spiral enteroscopy-assisted ERCP after Roux-en-Y reconstructive surgery and bilioenteric anastomosis: first clinical case. VideoGIE. 2020;5:311-3.
    Pubmed KoreaMed CrossRef
  43. Beyna T, Arvanitakis M, Schneider M, Gerges C, Hoellerich J, Devière J, et al. Total motorized spiral enteroscopy: first prospective clinical feasibility trial. Gastrointest Endosc. 2021;93:1362-70.
    Pubmed CrossRef
  44. Lo SK. ERCP in surgically altered anatomy. In: Baron TH, Kozarek RA, Carr-Locke DL, editors. ERCP. 3rd ed. Philadelphia: Elsevier; 2019, p. 288-307.
    CrossRef
  45. Krutsri C, Kida M, Yamauchi H, Iwai T, Imaizumi H, Koizumi W. Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. World J Gastroenterol. 2019;25:3313-33.
    Pubmed KoreaMed CrossRef
  46. Doshi B, Yasuda I, Ryozawa S, Lee GH. Current endoscopic strategies for managing large bile duct stones. Dig Endosc. 2018;30(Suppl 1):59-66.
    Pubmed CrossRef
  47. Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc. 2011;25:2592-6.
    Pubmed CrossRef
  48. Tønnesen CJ, Young J, Glomsaker T, Mala T, Løberg M, Bretthauer M, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP after Roux-en-Y gastric bypass. Endoscopy. 2020;52:654-61.
    Pubmed CrossRef