Motorized spiral enteroscopy in altered anatomy: Balancing clinical success with safety challenges

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y-anatomy is technically challenging and additional techniques including balloon-assisted enteroscopy, endoscopic ultrasound (EUS) guided, and percutaneous approaches offers only modest success rates. Motorized spiral enteroscopy (MSE)-assisted ERCP (MSE-ERCP) has emerged as a potential alternative. In a retrospective study by Nennstiel <i>et al</i>, MSE-ERCP achieved high success rates for biliary entry (88%) and therapeutic intervention (83%). However, outcomes varied significantly between bilioenteric anastomosis (93%) and native papilla (63%), underscoring the importance of anatomy-driven procedural selection. Despite encouraging efficacy, the global withdrawal of the MSE platform due to serious device-related complications highlights the ongoing balance between feasibility and safety. Future directions should prioritize refinements in device engineering, multicenter prospective trials comparing MSE with balloon-assisted and EUS-guided techniques, and systematic outcome stratification by anatomical subgroup. Such efforts will be critical to defining the role of MSE within the therapeutic algorithm for surgically altered anatomy.