ERCP using single-balloon instead of double-balloon enteroscopy in patients with Roux-en-Y anastomosis.

necrosectomy and a Roux−en−Y anasto− mosis. Before surgery the patient had un− dergone an endoscopic retrograde chol− angiopancreatography (ERCP) with bili− ary stent placement, but this stent could not be removed intra−operatively. ERCP was carried out using the Fujinon dou− ble−balloon enteroscope (EN−450T5I, Fu− jinon, Saitama, Japan). For the ERCP we did not place a balloon on the tip of the enteroscope. Advancement of the entero− scope and overtube was accomplished using the push−and−pull method. Once the anastomosis was localized, the over− tube was advanced towards the tip of the scope and the balloon was inflated. The enteroscope was then advanced into the afferent loop, and once it was 20 cm in− side of the loop, the overtube balloon was deflated and advanced towards the tip of the scope. These push−and−pull maneuvers were repeated until the pouch of the afferent limb was visualized. The protruding stent helped localize the ma− jor papilla (l" Fig. 1). The stent was then grasped with a snare and retrieved (l" Fig. 2). A 36−year−old man with chronic pancrea− titis underwent a pylorus−preserving Whipple’s operation with Roux−en−Y he− paticojejunostomy. He presented because of cholestasis. ERCP was carried out using the single−balloon method described above. Sludge was found “glued” to the orifice of the hepaticojejunostomy (l" Fig. 3). The sludge was removed using a stone retrieval basket (l" Fig. 4 and 5 ). There are recent case reports on the feasi− bility of performing ERCP with the dou− ble−balloon enteroscopy in patients with Roux−en−Y anastomosis [1,2]. Our cases suggest that ERCP using the single−bal− loon enteroscopy approach permits bili− ary interventions in patients with Roux− en−Y anastomosis. A potential advantage of using a single−balloon technique is time saving, as described for single−bal− loon colonoscopy [3]. In addition, occa− sionally the balloon of the scope slips over the tip, diminishing the endoscopic view and thus interfering with diagnostic and therapeutic interventions.