A facilitated method for endoscopic interventions at the bile duct after Roux-en-Y reconstruction using double balloon enteroscopy

Endoscopic retrograde cholangiography (ERC) after Roux-en-Y reconstruction and modified BII surgery or duodenopancreatectomy is considerably more difficult than ERC under normal anatomic conditions. If the common bile in the afferent loop cannot be reached by a common lateral-viewing duodenoscope because of excessive intestinal length, it has recently become possible to use double balloon enteroscopy (DBE) for ERC to reach the common bile duct. Cannulating the bile duct via DBE in these postoperative settings remains one of the most difficult ERCP manipulations because of the lack of an Albarran lever and the use of extra long ERCP accessories. Here, we report on a facilitated method for endoscopic interventions at the bile duct in postoperative settings with a long afferent loop using DBE. For facilitation of interventions the enteroscope can be exchanged for a 110-cm-long conventional gastroscope after incision of the overtube in three quarters of its circumference. Care has to be taken that the pressure line for the balloon remains intact. The huge benefit of this facilitated method is the use of standard endoscopic material like guides, catheters and papillotomes.