Endoscopic Treatment for Pancreatobiliary Diseases in Patients with Surgically Altered Anatomy: A Perspective from Double-Balloon Endoscopy.

BACKGROUND: The number of patients with surgically altered anatomy (SAA) is increasing worldwide. In these patients, pancreatobiliary disease is difficult to treat, because a conventional duodenoscope cannot reach the papilla or the bilioenteric anastomosis through the long reconstructed limb. For many years the main treatment options were reoperation or percutaneous drainage, both of which are invasive. SUMMARY: Double-balloon endoscopy (DBE), first reported in 2001, made it possible to insert the endoscope stably through the long limb and to reach the target perorally. The short-type DBE, and later a newly designed short-type DBE, then made therapeutic ERCP practical, because standard ERCP devices could be used. In a Japanese multicenter prospective study of 311 patients with SAA, the target site was reached in 97.7% (304/311) and the overall procedural success rate of 92.3% (287/311). Among the 283 patients requiring treatment, therapeutic success was achieved in 97.9% (277/283). Adverse events occurred in 10.6% (33/311), and 32 of the 33 events were managed conservatively. In this review we describe how DBE-assisted ERCP (DBE-ERCP) developed, summarize the current evidence, and discuss how it should be positioned relative to single-balloon endoscopy (SBE), interventional endoscopic ultrasound (EUS), and percutaneous drainage. KEY MESSAGES: DBE-ERCP and interventional EUS should be regarded as complementary approaches. DBE-ERCP is an important first-line option for many benign biliary disorders in non-Roux-en-Y gastric bypass SAA, particularly when preservation of the native papilla or surgical anastomosis and repeated intervention are important. Alternative approaches should be considered early in selected settings, including interventional EUS after failed balloon-endoscopy access or in malignant biliary obstruction, and EDGE or laparoscopy-assisted ERCP in Roux-en-Y gastric bypass anatomy when appropriate expertise is available. Treatment should be individualized according to the reconstruction anatomy, disease target, need for repeat intervention, and local expertise.