What is the advantage of a passive bending segment in balloon enteroscopy-assisted ERCP?

Yane et al. recently published an article on the usefulness of short-type single-balloon enteroscope (SBE) prototypes to perform balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (ERCP) [1]. They used three different short-type SBEs (152 cm), and two of these were equipped with passive bending and force transmission (SIF-Y0004-V01 and SIF-Y0015) to perform ERCP in patients with Billroth II gastrectomy, pancreaticoduodenectomy, short-limb Roux-en-Y gastrectomy, and hepaticojejunostomy. Factors determining therapeutic success were type of surgical reconstruction, second attempt ERCP, and the use of a transparent cap [1]. However, the possible advantage of the passive bending segment with force transmission is not mentioned. A passive bending segment may help to overcome sharp angulations when introducing an endoscope into a tortuous intestinal limb, an endoscopic feature that is difficult to measure [2].

We recently performed a successful SBE-assisted ERCP using the SIF-Y0011 prototype in a patient with long-limb Roux-en-Y gastric bypass. The SIF-Y0011 prototype is a 200 cm long SBE with a 3.2 mm working channel and a passive bending segment with force transmission near the 20 cm marker. A 43-year-old woman was referred for urgent SBE-assisted ERCP because of biliary leak from the cystic stump after recent cholecystectomy. She had undergone bariatric long-limb Roux-en-Y gastric bypass 1 year earlier. We performed the initial ERCP using the SIF-Y0011 prototype, and treated the biliary leak with sphincterotomy and placement of a 7 Fr plastic stent in the common bile duct. The patient recovered well from the biliary leak. Abdominal radiography 3 months later confirmed the presence of the biliary stent, which we tried to remove using the conventional SIF-Q180 SBE without the passive bending feature. However, after trying for 60 minutes to remove the stent, we were not able to reach the major papilla through the tortuous afferent limb. We rescheduled the procedure using the SIF-Y0011 prototype, which allowed us to reach the papilla and pull out the plastic biliary stent, which had been in place for 7 months.

The direct advantage of a passive bending segment with force transmission is difficult to measure in a single endoscopy procedure. However, this case clearly illustrates the benefit of the passive bending feature of the SBE to overcome difficult intestinal angulations. We attempted three SBE-assisted ERCP procedures in the same patient with long-limb Roux-en-Y gastric bypass, and only those performed using the SIF-Y0011 SBE were successful, illustrating the usefulness of passive bending with force transmission.

Reaching the biliary tract remains a challenge in patients with altered anatomy, especially in long-limb Roux-en-Y [3]. New developments in balloon enteroscopy aim to increase the success rate of therapeutic ERCP [4]. Passive bending with force transmission represents another endoscopic improvement [2]. It would be interesting to know whether Yane et al. also studied the role of passive bending in their recently published series [1].

• References

• 1 Yane K, Katanuma A, Maguchi H. et al. Short-type single-balloon enteroscope-assisted ERCP in postsurgical altered anatomy: potential factors affecting procedural failure. Endoscopy 2017; 49: 1-4
• 2 Yamauchi H, Kida M, Okuwaki K. et al. Passive-bending, short-type single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in Roux-en-Y anastomosis patients. World J Gastroenterol 2015; 21: 1546-1553
• 3 De Koning M, Moreels TG. Comparison of double-balloon and single-balloon enteroscope for therapeutic endoscopic retrograde cholangiography after Roux-en-Y small bowel surgery. BMC Gastroenterology 2016; 16: 98
• 4 Moreels TG, Kouinche Madenko N. et al. Therapeutic enteroscopy using a new single-balloon enteroscope: a case series. Endosc Int Open 2016; 4: E918-921