Tip‐Balloon Anchored Retroflex (T‐ <scp>BAR</scp> ) Method for Double Balloon Endoscopy‐Assisted <scp>ERCP</scp> in Roux‐en‐Y Anatomy

Double Balloon Endoscopy-assisted ERCP (DBE-ERCP) with a preserved papilla can fail when retroflex positioning is unstable and the catheter cannot be aligned coaxially with the bile duct [1-4]. We describe the Tip-Balloon Anchored Retroflex (T-BAR) technique, a modified retroflex position technique, which uses the tip balloon of a double-balloon endoscope as a fixation point (Figure 1). A man in his 70s with choledocholithiasis had undergone distal gastrectomy with Roux-en-Y reconstruction (Video S1). The papilla was visualized at the 6 o'clock position, but the bile duct axis was nearly perpendicular to the catheter axis and selective biliary cannulation failed. We attempted the retroflex position; however, the scope tip repeatedly slid toward the blind end, preventing stable positioning. Keep the papilla in view, often at the 6 o'clock position [5]. Inflate the tip balloon for gentle fixation to the intestinal wall. Using the inflated balloon as an anchor/pivot, slowly advance the scope while applying down angulation to obtain a stable retroflex view without slipping into the blind end, while maintaining a working distance from the papilla (Figure 2). Standard biliary cannulation is then performed. The balloon is deflated, and treatment proceeds. The T-BAR method is a useful technique for optimizing biliary axis alignment during DBE-ERCP in patients with an intact ligament of Treitz and native duodenal papilla. The T-BAR technique can be applied regardless of overtube balloon position, scope loop formation, or the endoscopic orientation of the papilla. However, it is less suitable when the papilla is located close to the blind end, as this limits scope maneuverability. Avoid excessive insufflation while the tip balloon is inflated to prevent blind-limb overdistension, and use gentle, controlled scope manipulation to reduce the risk of perforation. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Video S1: jhbp70094-sup-0001-Supinfo.zip. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.