Modified single-balloon endoscopy for ERCP in a patient with Billroth II gastrectomy.

An 84-year-old man with a history of hepatocellular carcinoma treated by transcatheter arterial chemoembolization and percutaneous ethanol injection therapy 2 years previously was admitted with jaundice. Magnetic resonance cholangiopancreatography (MRCP) showed a tumor invading the bifurcation of the common bile duct with bilateral intrahepatic duct dilatation (●" Fig.1). Endoscopic retrograde cholangiopancreatography (ERCP) was considered but as the patient had undergone a previous Billroth II gastrectomy and was concerned about possible complications, we held back from performing this procedure. A modified single-balloon enteroscopyassisted ERCP was planned instead, using a sliding tube with a balloon (XST-SB1; Olympus) and a balloon controller (XMAJ1725; Olympus). The sliding tube has a working length of 132cm, with outer and inner diameters of 13.2mm and 11mm respectively, and has a silicone balloon at its tip [1]. An adequate aperturewasmade in the overtube at a point 75cm from its tip on the side opposite to the pressure line. A conventional forward-viewing upper gastrointestinal endoscope with this modified single balloon was used to perform ERCPby the standardsingle-balloonmethod (●" Fig.2). The papillawas found via the afferent loop and a plastic stent was successfully placed with no complications (●" Fig.3 and●" Fig.4). It is usually difficult to perform ERCP in postoperative patients because of their altered anatomy. Balloon-assisted enteroscopy, with either a double or single balloon, can be used for these patients [1,2]. Although single-balloon enteroscopy-assisted ERCP is an accepted method, some endoscopists believe that “short-type” double-balloon enteroscopy is more effective in suchpatients [3]. In onemulticenter experience of overtube-assisted enteroscopic ERCP in patients with surgically altered pancreaticobiliary anatomy, the overall success rates were 60% and 63% in single-balloon and double-balloon procedures respectively. There was no significant difference between ERCPs performed by single-balloon or double-balloon enteroscopy [4]. There are many published case reports using double-balloon enteroscopy for ERCP in patients with altered anatomy, but reports of single-balloon enteroscopyassisted ERCPs are rare [1,5,6]. One reason for this is that double-balloon enteroscopy was developed before single-balloon enteroscopy. The other reason is that “short” double-balloon enteroscopy is easy to use for ERCP in patients with altered anatomy. Single-balloon enteroscopy has a 200-cm working length and the accessories are very limited [7]. Itoi et al. developed one possible method for single-balloon enteroscopy-assisted ERCP [1]. They performed traditional single-balloon enteroscopy first; they then made an aperture in the overtube at a point 100cm from its tip. A conventional forward-viewing upper gastrointestinal endoscope was then substituted for the Fig.1 Magnetic resonance cholangiopancreatography (MRCP) in an 84-year-old man with a history of hepatocellular carcinoma showing a tumor invading the bifurcation of common bile duct.