How to perform balloon assisted enteroscopic ERCP? – Current status and tips for procedures Ampullary intervention for bile duct stones in patients with surgically altered anatomy Kei Ito, Kaori Masu, Yoshihide Kanno, Tetsuya Ohira and Yutaka Noda Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan Transpapillary endoscopic treatment is a standard technique for the treatment of bile duct stones. This technique includes biliary cannulation, ampullary interventions such as endoscopic sphinc- terotomy (EST) and endoscopic papillary balloon dilation (EPBD), and stone removal. In patients with Roux-en-Y anastomosis, the transpapillary approach using an ordinary scope has been challenging. A recently developed single-/double-balloon entero- scope enables therapeutic endoscopic retrograde cholangiopan- creatography to be carried out in such cases. EST using a balloon enteroscope is often difficult to carry out as a result of restrict- ion of scope maneuverability or inadequate direction of the accessory. Although EPBD is easy to carry out for any anatomy, large or multiple stones are difficult to remove by EPBD only because of insufficient opening of Vater’s papilla. Endoscopic papillary large-balloon dilation following EST is reported to be useful for the treatment of large and/or multiple stones. This technique is also useful for the treatment of bile duct stones in patients with Roux-en-Y anastomosis. Key words: endoscopic papillary balloon dilation (EPBD), endo- scopic papillary large-balloon dilation (EPLBD), endoscopic sphincterotomy (EST), enteroscopy, Roux-en-Y anastomosis INTRODUCTION F OR TRANSPAPILLARY ENDOSCOPIC treatment of bile duct stones, ampullary intervention such as endo- scopic sphincterotomy (EST), endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large-balloon dilation (EPLBD) are generally carried out before the removal of bile duct stones. For several decades, the percutaneous transhepatic approach or surgical treatment was the standard technique for patients with Roux-en-Y (RY) anastomosis. Endoscopic retrograde cholangiopancreatography (ERCP) using a standard scope remains technically challenging as a result of the inability to reach the anastomosis. A recently developed single-/double-balloon enteroscope makes it pos- sible to carry out therapeutic transpapillary ERCP for such cases. 1–11 Ampullary intervention for bile duct stones in patients with surgically altered anatomy is discussed herein. ENDOSCOPIC TREATMENT FOR BILE DUCT STONES IN PATIENTS WITH SURGICALLY ALTERED ANATOMY S URGICALLY ALTERED ANATOMY with an intact papilla includes Billroth I/II gastrectomy (B-I/II) and RY anastomosis. In cases of B-I/II, a duodenoscope, a forward- viewing scope or an oblique-viewing scope is usually used for therapeutic ERCP. The success rate and safety of these procedures have been reported to be comparable to those with native anatomy. 12 However, in patients with RY anatomy, ERCP-related procedures using a traditional endo- scope have been technically challenging because of the inability to reach Vater’s papilla. For several decades, the percutaneous transhepatic approach or surgical treatment was the standard technique for such cases. A balloon-assisted enteroscope, which was developed for the diagnosis and treatment of small-bowel diseases, 13 has been reported to be useful for transpapillary endoscopic treatment of bile duct stones in patients with RY anastomosis. 1–11 Although some authors have indicated that the single-balloon enteroscope (SBE) is inferior to the double-balloon enteroscope (DBE) for achieving total enter- oscopy, 14 the success rates of therapeutic ERCP using these scopes have been reported to be similar. 5,6 Nowadays, in terms of scope length, two types of balloon- assisted enteroscope are commercially available in Japan (i.e. a long-type DBE/SBE [200 cm in length] and a short-type DBE [152 cm in length]). Although dedicated long-length accessories are necessary for carrying out ERCP-related procedures with a long-type DBE/SBE, ordi- nary accessories can be used with a short-type DBE. A short-type SBE (152 cm in length) is under development and will be commercially available in the near future. Its passive Corresponding: Kei Ito, Department of Gastroenterology, Sendai City Medical Center, 5-22-1, Tsurugaya, Miyagino-ku, Sendai, Miyagi 983-0824, Japan. Email: keiito@openhp.or.jp Received 29 November 2013; accepted 12 January 2014. Digestive Endoscopy 2014; 26 (Suppl. 2): 116–121 doi: 10.1111/den.12250 116