Long Double-Balloon Enteroscopy for Biliary Access in Surgically Altered Anatomy: Outcomes and Technical Adaptations in Resource-Limited Settings

Long Double-Balloon Enteroscopy for Biliary Access in Surgically Altered Anatomy: Outcomes and Technical Adaptations in Resource-Limited Settings | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Long Double-Balloon Enteroscopy for Biliary Access in Surgically Altered Anatomy: Outcomes and Technical Adaptations in Resource-Limited Settings Hani Abou Taleb, Ahmed Abdo Yousif, Muhammed Abdelghaffar, Yasmine Ahmed, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8560756/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background and Aims: Biliary obstruction in patients with surgically altered anatomy (SAA) poses significant challenges, particularly in resource-limited settings lacking short enteroscopes. This study evaluated the efficacy and safety of long double-balloon enteroscopy (DBE) with long guiding catheters and controlled radial expansion (CRE) balloons for biliary access. Methods: Between January 2021 and December 2023, 26 consecutive SAA patients with biliary obstruction underwent therapeutic long DBE at three tertiary centers in Egypt. The primary outcomes were technical success (defined as anastomosis reach and successful cannulation) and clinical success (defined as bilirubin normalization at 4 weeks). Secondary outcomes included procedure characteristics, complications, and the need for alternative interventions. Results: Technical success was achieved in 84.6% (22/26). Mean procedure time was 89 ± 32 minutes, with Roux-en-Y hepaticojejunostomy cases requiring longer times than choledochojejunostomy (102 ± 28 vs. 78 ± 24 min, p = 0.03). Bilirubin decreased significantly from 5.4 ± 3.1 to 1.2 ± 0.7 mg/dL at 4 weeks (p < 0.001). Complications occurred in 11.5% (3/26): two mild cholangitis and one self-limited bleeding. Four failures required alternative interventions (EUS-guided hepaticogastrostomy, percutaneous drainage, or Randex Voux technique). Conclusion: Long DBE with long guiding catheters enables effective biliary access in SAA patients, achieving outcomes comparable to high-resource settings. This strategy represents a practical solution for centers lacking short enteroscopes. Enteroscopy biliary stricture Roux-en-Y resource-limited ERCP Figures Figure 1 Figure 2 Figure 3 Introduction Managing biliary obstruction in patients with surgically altered anatomy (SAA) represents a major challenge in modern gastroenterology. With the rising prevalence of bariatric and hepatobiliary surgeries, the number of patients with Roux-en-Y reconstructions, hepaticojejunostomies, and Whipple procedures has increased significantly, at an estimated annual rate of 12–15% worldwide [ 1 ]. In well-resourced centers, short double-balloon enteroscopy (DBE)- or single-balloon enteroscopy (SBE)-assisted ERCP is the gold standard, with success rates exceeding 90% in expert hands [ 2 , 3 ]. However, these devices are not widely available in many resource-limited settings due to high costs and infrastructure demands [ 4 ]. Consequently, there is growing interest in adapting conventional long DBE systems for therapeutic biliary interventions, using innovative approaches and accessories to overcome technical barriers [ 5 ]. Among SAA configurations, Roux-en-Y reconstructions pose the greatest challenges. The long alimentary limb (often > 150 cm), sharp angulations at the jejunojejunal anastomosis, and difficult-to-reach biliary-enteric anastomoses significantly complicate endoscopic access [ 6 , 7 ]. These anatomical variations require specialized techniques that differ substantially from conventional ERCP. In many low-resource environments, percutaneous transhepatic approaches remain the default despite higher complication rates and poorer patient tolerability [ 8 ]. Endoscopic alternatives, if feasible, offer clear advantages in terms of patient comfort, reduced infection risk, and improved long-term outcomes [ 9 ]. By demonstrating the feasibility of long DBE with strategic use of guiding catheters and dilation balloons, this study aims to provide a practical roadmap for centers where short enteroscopes are unavailable. Methods Study Design and Setting We conducted a prospective observational study across three tertiary referral centers between January 2021 and December 2023. The institutions serve as a referral center for complex hepatobiliary cases, including patients with surgically altered anatomy. The study population comprised adults (≥18 years) with surgically altered upper gastrointestinal anatomy presenting with clinically significant biliary obstruction. Inclusion criteria required either: (1) biochemical evidence of cholestasis (total bilirubin >2 mg/dL) with compatible imaging findings, or (2) clinical cholangitis meeting Tokyo Guidelines 2018 criteria [10]. We excluded patients with uncorrectable coagulopathy (INR >1.5 despite vitamin K administration), active upper gastrointestinal obstruction preventing scope advancement, or pregnancy. Equipment and Procedure: Procedures were performed using a Fujifilm EN-580T long DBE system (working length 2000 mm, distal diameter 9.4 mm, channel 3.2 mm) with CO₂ insufflation. The accessories were selected for their compatibility with long-scope applications: Guiding Catheters: Boston Scientific 5-7 Fr devices (450 cm length) served as the primary cannulation tools. These were particularly valuable for maintaining wire access during complex maneuvers (Figure 1). Dilation Devices: CRE balloons (6-10-12 mm diameter) were employed for stricture management when indicated. The balloons were inflated gradually under fluoroscopic guidance and guided by pressure monitor to minimize trauma risk. Guidewires: We exclusively used 450 cm hydrophilic wires, 0.035 inch. Basket: A Special long basket used in some cases for stone extraction (Figure 2). The procedural approach was standardized across all centers with the following key steps: Patients underwent 8 hours of fasting and received prophylactic intravenous ciprofloxacin (400 mg) 30 minutes before the procedure. General anesthesia was administered, and the patient was monitored by an anesthesia team throughout the procedure. Identifying the biliary limb: The afferent limb was suggested by acute angulation at the jejunojejunostomy, bile-stained fluid, reduced peristalsis, and a course toward the right upper quadrant. When the wrong limb was entered, endoscopic clipping was used to mark and avoid re-entry [11–13]. Upon reaching the anastomosis, cannulation was attempted with a guiding catheter preloaded with a long guidewire (Fig. 1). Contrast confirmed biliary opacification (Fig. 2). CRE balloons were used for strictures >3 mm (Fig. 3). We preferentially used 7 Fr plastic stents due to their compatibility with long delivery systems and the scope accessory channel. Definitions and Outcome Primary outcomes included: Technical success: Defined as both (a) reaching the bilioenteric anastomosis and (b) achieving successful cannulation with therapeutic intervention [14]. Failure: failure to reach the biliary anastomosis (Enteroscopy failure) or failure of biliary cannulation (ERCP failure). Clinical success: Bilirubin normalization (<1.2 mg/dL) at 4-week follow-up accompanied by symptom resolution [15]. Secondary endpoints encompassed procedure duration (scope insertion to withdrawal), fluoroscopy time, and complication rates graded by ASGE criteria [16]. Ethical approval The study protocol received approval from the institutional review board at The General Organization for Teaching Hospitals and Institutes, GOTHI (IRB: HAM00167), and was conducted in accordance with the World Medical Association Declaration of Helsinki. Consecutive patients meeting the inclusion criteria were enrolled after providing written informed consent. Clinical trial number: not applicable. Statistical analysis: Continuous variables reported as mean±SD; categorical variables as percentages for each group. Comparisons used Paired t-tests for lab values, Chi-square for categorical variables, and ANOVA for procedure time differences. Continuous variables were presented as medians with interquartile ranges and compared using the Mann-Whitney U test. A statistical significance threshold was established at p<0.05. All statistical analyses were conducted using IBM SPSS software, version 23 (IBM, Armonk, NY, USA). Results Patient Characteristics The study cohort comprised 26 consecutive patients (mean age 49.5 ± 11.2 years, 38.5% male) with SAA requiring therapeutic biliary intervention. The anatomical distribution revealed 14 (53.8%) Roux-en-Y hepaticojejunostomies, 9 (34.6%) choledochojejunostomies, and 3 (11.5%) Whipple procedures. Time since original surgery averaged 28.4 ± 18.2 months, reflecting both recent and remote surgical interventions (Table 1). Baseline laboratory values demonstrated significant cholestasis, with a mean total bilirubin of 5.4 ± 3.1 mg/dL and direct bilirubin of 4.2 ± 2.8 mg/dL. Hepatic enzyme elevations were notable for alkaline phosphatase (988 ± 650 U/L) and GGT (295 ± 280 U/L), consistent with obstructive pathophysiology. The ALT levels (98 ± 85 U/L) suggested varying degrees of hepatocellular injury accompanying the biliary obstruction (Table 1). Procedural Outcomes Technical success was achieved in 22 of 26 procedures (84.6%). Guiding catheters facilitated selective cannulation in 20 of 22 cases (90.9%), with failures occurring exclusively in patients with Whipple anatomy. Controlled radial expansion (CRE) balloons were required in 4 patients; although all strictures were successfully dilated (100%), selective biliary cannulation was obtained in only 2 of these cases (50%) (Table 2). The mean procedure time was 89 ± 32 minutes. Procedures in patients with Roux-en-Y hepaticojejunostomy required significantly longer times than those with choledochojejunostomy (102 ± 28 vs. 78 ± 24 minutes, p = 0.03), reflecting the complexity of navigating long afferent limbs (Table 3). Fluoroscopy times showed a similar trend (18 ± 6 vs. 14 ± 5 minutes), though this difference did not reach statistical significance ( p = 0.12). Clinical Outcomes Clinical success was achieved in 22 patients (84.6%). Serum bilirubin decreased significantly from 5.4 ± 3.1 mg/dL at baseline to 1.2 ± 0.7 mg/dL at 4 weeks ( p < 0.001). In parallel, liver enzymes normalized, with ALT declining to 38 ± 28 U/L and alkaline phosphatase to 220 ± 180 U/L (both p < 0.001) (Table 4). When contextualized with international data (Table 5), our outcomes are comparable to those reported from high-resource centers using short DBE systems, such as Itoi et al. (94% success, 9% complications) and Khashab et al. (89% success, 11% complications). Importantly, our success rate aligns closely with the pooled rates summarized by Tanisaka et al. (87–93%), underscoring the feasibility of long DBE even in settings without short enteroscopes. Complications Adverse events occurred in 3 patients (11.5%). Two developed mild post-procedure Cholangitis, both managed with a short-course third-generation quinolone regimen, and one experienced self-limited bleeding following CRE dilatation that was controlled endoscopically. No perforations, severe bleeding, pancreatitis, or procedure-related deaths were observed. Among the 4 technical failures, alternative drainage methods were pursued, including endoscopic ultrasound-guided hepaticogastrostomy ( n = 1), percutaneous transhepatic biliary drainage ( n = 1), and the Randex Voux technique ( n = 2). Discussion This multicenter prospective study demonstrates that long DBE combined with guiding catheter techniques is both feasible and effective for biliary access in patients with surgically altered anatomy (SAA). Our technical and clinical success rate of 84.6% is comparable to outcomes reported from high-resource centers employing short DBE systems, where success rates typically exceed 85–90% [2,3,17]. Similarly, our overall adverse event rate of 11.5% is consistent with the pooled data summarized by Tanisaka et al., who reported success rates of 87–93% and complication rates of 7–12% across multiple international studies [19]. Taken together, these findings underscore that long DBE, when supplemented with tailored technical modifications, can provide therapeutic outcomes on par with advanced centers, even in resource-limited settings. Procedural duration varied significantly by anatomy, with Roux-en-Y cases requiring longer times compared with choledochojejunostomies. This reflects the inherent challenges of long afferent limb navigation, including looping, sharp angulations, and scope instability. Loop reduction maneuvers, careful fluoroscopic guidance, and effective two-operator coordination were critical to achieving success in these cases, as highlighted in prior device-assisted enteroscopy studies [11,12]. The extended fluoroscopy times observed in Roux-en-Y cases, although not statistically significant, further emphasize the technical demands of this anatomy. Technical Innovations The adoption of guiding catheters played a pivotal role in overcoming the intrinsic limitations of long enteroscopes, particularly their restricted accessory length. By facilitating stable guidewire passage, reliable contrast injection, and controlled stent deployment, the guiding catheter significantly increased procedural success. The “stent-in-catheter” method, applied in five patients, proved especially practical, allowing for precise stent placement without the need for specialized short-scope accessories. Similarly, controlled radial expansion (CRE) balloons were effective for stricture dilation, though their role in primary biliary cannulation was limited, consistent with prior reports [21]. These adaptations highlight the value of simple, reproducible techniques that expand the therapeutic potential of long DBE in environments where short enteroscopes and specialized accessories are not available. Our results reinforce the clinical relevance of long DBE as a viable alternative to short DBE or more invasive modalities in SAA patients. In the absence of short enteroscopes, reliance on percutaneous or surgical drainage has historically been high, often associated with greater morbidity and reduced patient comfort [22]. By demonstrating comparable outcomes with long DBE, our study provides evidence that safe, effective endoscopic therapy can be delivered in low-resource settings without compromising success or safety. This has important implications for global endoscopy practice, particularly in regions where healthcare systems face significant equipment and cost. Study Limitations This study has several limitations. The overall cohort size was modest, particularly with respect to patients who had undergone Whipple surgery, in whom most technical failures were observed. The relatively short follow-up period also precludes a comprehensive evaluation of long-term outcomes, including the durability of stricture dilatation, stent patency, and the risk of recurrent obstruction. Nevertheless, despite these constraints, this work represents one of the largest prospective series to date assessing the role of long double-balloon enteroscopy for biliary access in surgically altered anatomy within a resource-limited setting. Conclusion Long DBE with guiding catheter-assisted cannulation achieves effective biliary access in SAA, with outcomes comparable to high-resource settings and acceptable safety. This approach is a cost-effective, practical solution for resource-limited centers. Larger multicenter studies are needed for validation. Declarations Conflict of interests: All authors did not have any conflicts of interest. Author contributions: Ghoneem Elsayed, Abou Taleb Hani, and Yousif Abdo Ahmed designed and organized this study, wrote the manuscript, and reviewed the patient data. Yousif Abdo Ahmed, Ahmed Yasmine, and Muhammed Abdelghaffar enrolled patients, collected detailed data, and reviewed the paper. Ahmed Yasmine reviewed the radiological assessment of the patients. Data Transparency Statement: The patient data used to support the findings of this study are available from the corresponding author upon reasonable request. Funding: No financial support was received. Author Contributions: - Study design and drafting: Elsayed Ghoneem, Hani Abou Taleb, Ahmed Abdo Yousif - Data collection: Ahmed Abdo Yousif, Muhammed Abdelghaffar, Yasmine Ahmed - Radiology review: Yasmine Ahmed - All authors reviewed and approved the final manuscript. Data Availability: Available from the corresponding author upon request. References Itoi T, Ishii K, Tanaka R, et al. Long- versus short-type double-balloon enteroscopy for therapeutic ERCP in patients with surgically altered anatomy: systematic review and meta-analysis. Gastrointest Endosc. 2021;93(4):890–9. Nabi Z, Reddy DN. Endoscopic management of biliary issues in patients with surgically altered anatomy. Gastrointest Endosc Clin N Am. 2022;32(1):157–76. Skinner M, Popov V, Pleskow D. ERCP in surgically altered anatomy: how we do it. Clin Gastroenterol Hepatol. 2021;19(5):892–9. Lenze F, Nowacki TM, Beyna T, et al. Enteroscopy in the management of biliary tract disease in patients with surgically altered anatomy: a systematic review and meta-analysis. Gastrointest Endosc. 2020;91(2):312–9. Shah RJ, Smolkin M, Yen R, et al. A multicenter U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy. Gastrointest Endosc. 2017;85(3):483–94. Tsujino T, Katanuma A, Kawakami H. Double-balloon enteroscopy-assisted ERCP in patients with surgically altered anatomy: tips and tricks. Gastrointest Endosc. 2020;92(1):47–56. Katanuma A, Matsumori T, Hayashi T, et al. Techniques of device-assisted enteroscopy for ERCP in altered gastrointestinal anatomy. Dig Endosc. 2022;34(2):199–214. Ogura T, Higuchi K. Technical tips and recent development of endoscopic ultrasound-guided hepaticogastrostomy. Dig Endosc. 2022;34(1):50–8. Tyberg A, Desai AP, Kumta NA, et al. EUS-guided biliary drainage after failed ERCP: a novel algorithm individualized to patient anatomy. Gastrointest Endosc. 2021;93(4):859–66. Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):17–30. ASGE Technology Committee, Enteroscopy. Gastrointest Endosc. 2021;93(5):1095–113. Park TY, Choi JS, Oh HC, et al. Preoperative MRCP to plan endoscopic interventions in patients with surgically altered anatomy: does it help? Clin Radiol. 2021;76(3):215–22. Tanisaka Y, Mizuide M, Fujita A, et al. Balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. Int J Gastrointest Interv. 2021;10(1):1–13. Khashab MA, Bukhari M, Baron TH, et al. International multicenter comparative trial of transluminal EUS-guided biliary drainage versus hepatogastrostomy for malignant distal biliary obstruction. Endosc Int Open. 2020;8(6):E751–60. Kunda R, Pérez-Miranda M, Will U, et al. EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after failed ERCP: a multicenter international collaborative study. Surg Endosc. 2022;36(8):5678–85. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71(3):446–54. Skinner M, Gutierrez JP, Neumann H, et al. ERCP with the short double-balloon enteroscope: a multicenter U.S. experience. Gastrointest Endosc. 2014;80(4):717–25. Moreels TG. Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. Curr Opin Gastroenterol. 2017;33(5):324–31. Tanisaka Y, Mizuide M, Fujita A, et al. Balloon enteroscope-assisted ERCP in patients with surgically altered anatomy: a comprehensive review. Int J Gastrointest Interv. 2021;10(1):1–13. Inoue T, Okumura F, Sano H, et al. A new cannulation technique using a double-guidewire method in balloon enteroscopy-assisted ERCP. Endoscopy. 2021;53(2):E103–4. Kanno Y, Ito K, Koshita S, et al. Usefulness of catheter-assisted cannulation in difficult biliary access during balloon enteroscopy-assisted ERCP. Endosc Int Open. 2019;7(11):E1449–55. Angsuwatcharakon P, Rerknimitr R, Kullavanijaya P, et al. Outcome of endoscopic retrograde cholangiopancreatography in patients with altered anatomy. World J Gastroenterol. 2010;16(38):4695–701. Tables Table 1: Baseline Demographics and Clinical Features: Characteristic Value (n=26) Age (years) 49.5 ± 11.2 (20-69) Male gender 10 (38.5%) Surgical Anatomy: Roux-en-Y hepaticojejunostomy Choledochojejunostomy Whipple procedure 14 (53.8%) 9 (34.6%) 3 (11.5%) Time since surgery (months) 28.4 ± 18.2 Laboratory Values: Total bilirubin (mg/dL) Direct bilirubin (mg/dL) Alkaline phosphatase (U/L) GGT (U/L) ALT (U/L) 5.4 ± 3.1 4.2 ± 2.8 988 ± 650 295 ± 280 98 ± 85 Table 2: Procedure Outcomes, Technical Success by Anatomy Type: The Altered Anatomy N Reach Success Cannulation Success Guiding Catheter Used CRE Balloon Used Roux-en-Y 14 14 (100%) 12 (85.7%) 12 (85.7%) 2 (14.3%) Choledochojejunostomy 9 9 (100%) 8 (88.9%) 8 (88.9%) 1 (11.1%) Whipple 3 3 (100%) 2 (66.7%) 2 (66.7%) 1 (33.3%) Total 26 26 (100%) 22 (84.6%) 22 (84.6%) 4 (15.4%) *Overall cannulation success: 84.6% (22/26) Guiding catheter success: 90.9% (20/22), while CRE balloon success: 50% (2/4) Procedure Characteristics: *Mean procedure time is 89 ± 32 minutes: In cases with Roux-en-Y: 102 ± 28 min while in Choledochojejunostomy cases it is 78 ± 24 min (p=0.03) *Mean fluoroscopy time: 16 ± 7 minutes Table 3: Detailed Procedure Outcomes by Anatomy Type: Roux-en-Y (n=14) Choledochojejunostomy (n=9) Whipple (n=3) p-value Mean procedure time (min) 102 ± 28 78 ± 24 95 ± 31 0.03 Fluoroscopy time(min) 18 ± 6 14 ± 5 17 ± 4 0.12 Stricture dilation needed 9 (64.3%) 5 (55.6%) 2 (66.7%) 0.82 Stent placement 12 (85.7%) 7 (77.8%) 2 (66.7%) 0.61 Table 4: Clinical and Laboratory Post-Procedure Outcomes: Pre-Procedure 1 Week 4 Weeks p-value Total bilirubin (mg/dL) 5.4 ± 3.1 2.1 ± 1.2 1.2 ± 0.7 <0.001 ALT (U/L) 98 ± 85 45 ± 32 38 ± 28 <0.001 Alkaline phosphatase (U/L) 988 ± 650 450 ± 320 220 ± 180 <0.001 *Post-procedure related complications were 11.5%. Mild cholangitis developed in 2 cases (7.7%), and self-limited bleeding in 1 case (3.8%). No perforations or mortality encountered. Table 5: Comparison with Global studies Outcomes Study Country N Scope Type Success Rate Complication Rate Current study Egypt 26 Long DBE 84.6% 11.5% Itoi et al. Japan 112 Short DBE 94% 9% Khashab et al. USA 89 Short DBE 89% 11% Rahman et al. Bangladesh 45 Long DBE 78% 18% Tanisaka et al. (Review) Japan (multicenter) - Enteroscopy-assisted ERCP 87–93% 7–12% Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 29 Apr, 2026 Reviews received at journal 28 Apr, 2026 Reviewers agreed at journal 28 Apr, 2026 Editor invited by journal 24 Mar, 2026 Reviewers invited by journal 10 Feb, 2026 Editor assigned by journal 13 Jan, 2026 Submission checks completed at journal 13 Jan, 2026 First submitted to journal 09 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8560756","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588979117,"identity":"0c6cb78b-f2e6-40f0-b165-09caf29b76f6","order_by":0,"name":"Hani Abou Taleb","email":"","orcid":"","institution":"Beni-Suef University","correspondingAuthor":false,"prefix":"","firstName":"Hani","middleName":"Abou","lastName":"Taleb","suffix":""},{"id":588979120,"identity":"ac38bc09-60b8-4900-b448-f9e8de9b635a","order_by":1,"name":"Ahmed Abdo Yousif","email":"","orcid":"","institution":"Ahmed Maher Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Abdo","lastName":"Yousif","suffix":""},{"id":588979121,"identity":"d3b7922a-21ca-46e1-8e21-dca6a78e1ba4","order_by":2,"name":"Muhammed Abdelghaffar","email":"","orcid":"","institution":"Ahmed Maher Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Muhammed","middleName":"","lastName":"Abdelghaffar","suffix":""},{"id":588979123,"identity":"722e5d9e-fe56-4553-9927-d2d9b529559a","order_by":3,"name":"Yasmine Ahmed","email":"","orcid":"","institution":"Beni-Suef University","correspondingAuthor":false,"prefix":"","firstName":"Yasmine","middleName":"","lastName":"Ahmed","suffix":""},{"id":588979126,"identity":"e62eb4d4-76e4-4aab-93d5-829885c20b4e","order_by":4,"name":"Elsayed Ghoneem","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBAC+wYGNgiLvQEqdICAFgMGmBYemFLitUgkEK2F/dqDjzts5HRnvk78XPCHQY7vRgLjwy94tNgz8JQbzjyTZmx2O3ez9Mw2BmPJGwnMxjJ4beFJk+ZtO5y47XbuBmneBobEDTcS2KQlCGv5X7/t5tnNv3n+MNQDtbD/xq+F/RhQy4EEsxu826R52BgSDIC2MH7Abwub5My2ZMNtZ3K3WfO2SQA99rBZGo8OYFSyP5P42GYnb3b87ObbPH9s5PmOJx/8+AOfHvk3BshckCcYG5h58GlhYH+AKcaI15ZRMApGwSgYaQAATpJM5WBvstkAAAAASUVORK5CYII=","orcid":"","institution":"Mansoura University","correspondingAuthor":true,"prefix":"","firstName":"Elsayed","middleName":"","lastName":"Ghoneem","suffix":""}],"badges":[],"createdAt":"2026-01-09 12:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8560756/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8560756/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102621778,"identity":"8dd7468b-6471-41cc-8f42-088957aae671","added_by":"auto","created_at":"2026-02-13 16:53:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":105277,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1Longguidingcatheter.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8560756/v1/bbf9938345a378177fef7734.jpg"},{"id":102621779,"identity":"153b3602-b93d-462d-83ca-eb39dca121bb","added_by":"auto","created_at":"2026-02-13 16:53:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":109697,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8560756/v1/b5c36e0a34968bce9e25d4ac.jpg"},{"id":102621777,"identity":"0d9c314d-219f-452a-9f27-7a4d3c4507df","added_by":"auto","created_at":"2026-02-13 16:53:08","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":119627,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8560756/v1/0d99e9fad9fdd7c7a7e8813a.jpg"},{"id":102621829,"identity":"88b9a2a5-39b2-42b5-9258-4061f74fc1e6","added_by":"auto","created_at":"2026-02-13 16:53:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1188352,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8560756/v1/384d80e1-dc51-406d-a2e9-10da61cfaa6e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long Double-Balloon Enteroscopy for Biliary Access in Surgically Altered Anatomy: Outcomes and Technical Adaptations in Resource-Limited Settings","fulltext":[{"header":"Introduction","content":"\u003cp\u003eManaging biliary obstruction in patients with surgically altered anatomy (SAA) represents a major challenge in modern gastroenterology. With the rising prevalence of bariatric and hepatobiliary surgeries, the number of patients with Roux-en-Y reconstructions, hepaticojejunostomies, and Whipple procedures has increased significantly, at an estimated annual rate of 12\u0026ndash;15% worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn well-resourced centers, short double-balloon enteroscopy (DBE)- or single-balloon enteroscopy (SBE)-assisted ERCP is the gold standard, with success rates exceeding 90% in expert hands [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, these devices are not widely available in many resource-limited settings due to high costs and infrastructure demands [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, there is growing interest in adapting conventional long DBE systems for therapeutic biliary interventions, using innovative approaches and accessories to overcome technical barriers [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong SAA configurations, Roux-en-Y reconstructions pose the greatest challenges. The long alimentary limb (often\u0026thinsp;\u0026gt;\u0026thinsp;150 cm), sharp angulations at the jejunojejunal anastomosis, and difficult-to-reach biliary-enteric anastomoses significantly complicate endoscopic access [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These anatomical variations require specialized techniques that differ substantially from conventional ERCP.\u003c/p\u003e \u003cp\u003eIn many low-resource environments, percutaneous transhepatic approaches remain the default despite higher complication rates and poorer patient tolerability [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Endoscopic alternatives, if feasible, offer clear advantages in terms of patient comfort, reduced infection risk, and improved long-term outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. By demonstrating the feasibility of long DBE with strategic use of guiding catheters and dilation balloons, this study aims to provide a practical roadmap for centers where short enteroscopes are unavailable.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a prospective observational study across three tertiary referral centers between January 2021 and December 2023. The institutions serve as a referral center for complex hepatobiliary cases, including patients with surgically altered anatomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study population comprised adults (\u0026ge;18 years) with surgically altered upper gastrointestinal anatomy presenting with clinically significant biliary obstruction. Inclusion criteria required either: (1) biochemical evidence of cholestasis (total bilirubin \u0026gt;2 mg/dL) with compatible imaging findings, or (2) clinical cholangitis meeting Tokyo Guidelines 2018 criteria [10]. We excluded patients with uncorrectable coagulopathy (INR \u0026gt;1.5 despite vitamin K administration), active upper gastrointestinal obstruction preventing scope advancement, or pregnancy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Equipment and Procedure:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProcedures were performed using a Fujifilm EN-580T long DBE system (working length 2000 mm, distal diameter 9.4 mm, channel 3.2 mm) with CO₂\u0026nbsp;insufflation. The accessories were selected for their compatibility with long-scope applications:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eGuiding Catheters:\u0026nbsp;Boston Scientific 5-7 Fr devices (450 cm length) served as the primary cannulation tools. These were particularly valuable for maintaining wire access during complex maneuvers (Figure 1).\u003c/li\u003e\n \u003cli\u003eDilation Devices:\u0026nbsp;CRE balloons (6-10-12 mm diameter) were employed for stricture management when indicated. The balloons were inflated gradually under fluoroscopic guidance and guided by pressure monitor to minimize trauma risk.\u003c/li\u003e\n \u003cli\u003eGuidewires:\u0026nbsp;We exclusively used 450 cm hydrophilic wires, 0.035 inch.\u003c/li\u003e\n \u003cli\u003eBasket: A Special long basket used in some cases for stone extraction\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e(Figure 2).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe procedural approach was standardized across all centers with the following key steps:\u003c/p\u003e\n\u003cp\u003ePatients underwent 8 hours of fasting and received prophylactic intravenous ciprofloxacin (400 mg) 30 minutes before the procedure. General anesthesia was administered, and the patient was monitored by an anesthesia team throughout the procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentifying the biliary limb:\u003c/strong\u003e The afferent limb was suggested by acute angulation at the jejunojejunostomy, bile-stained fluid, reduced peristalsis, and a course toward the right upper quadrant. When the wrong limb was entered, endoscopic clipping was used to mark and avoid re-entry [11\u0026ndash;13].\u003c/p\u003e\n\u003cp\u003eUpon reaching the anastomosis, cannulation was attempted with a guiding catheter preloaded with a long guidewire (Fig. 1). Contrast confirmed biliary opacification (Fig. 2). CRE balloons were used for strictures \u0026gt;3 mm (Fig. 3). We preferentially used 7 Fr plastic stents due to their compatibility with long delivery systems and the scope accessory channel.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDefinitions and Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrimary outcomes included:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTechnical success: Defined as both (a) reaching the bilioenteric anastomosis and (b) achieving successful cannulation with therapeutic intervention [14].\u003c/li\u003e\n \u003cli\u003eFailure: failure to reach the biliary anastomosis (Enteroscopy failure) or failure of biliary cannulation (ERCP failure).\u003c/li\u003e\n \u003cli\u003eClinical success: Bilirubin normalization (\u0026lt;1.2 mg/dL) at 4-week follow-up accompanied by symptom resolution [15].\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eSecondary endpoints encompassed procedure duration (scope insertion to withdrawal), fluoroscopy time, and complication rates graded by ASGE criteria [16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The study protocol received approval from the institutional review board at The General Organization for Teaching Hospitals and Institutes, GOTHI (IRB: HAM00167),\u0026nbsp;and was conducted in accordance with the World Medical Association Declaration of Helsinki. Consecutive patients meeting the inclusion criteria were enrolled after providing written informed consent. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables reported as mean\u0026plusmn;SD; categorical variables as percentages for each group. Comparisons used Paired t-tests for lab values, Chi-square for categorical variables, and ANOVA for procedure time differences. Continuous variables were presented as medians with interquartile ranges and compared using the Mann-Whitney U test. A statistical significance threshold was established at p\u0026lt;0.05. All statistical analyses were conducted using IBM SPSS software, version 23 (IBM, Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study cohort comprised 26 consecutive patients (mean age 49.5 \u0026plusmn; 11.2 years, 38.5% male) with SAA requiring therapeutic biliary intervention. The anatomical distribution revealed 14 (53.8%) Roux-en-Y hepaticojejunostomies, 9 (34.6%) choledochojejunostomies, and 3 (11.5%) Whipple procedures. Time since original surgery averaged 28.4 \u0026plusmn; 18.2 months, reflecting both recent and remote surgical interventions (Table 1).\u003c/p\u003e\n\u003cp\u003eBaseline laboratory values demonstrated significant cholestasis, with a mean total bilirubin of 5.4 \u0026plusmn; 3.1 mg/dL and direct bilirubin of 4.2 \u0026plusmn; 2.8 mg/dL. Hepatic enzyme elevations were notable for alkaline phosphatase (988 \u0026plusmn; 650 U/L) and GGT (295 \u0026plusmn; 280 U/L), consistent with obstructive pathophysiology. The ALT levels (98 \u0026plusmn; 85 U/L) suggested varying degrees of hepatocellular injury accompanying the biliary obstruction (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedural Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTechnical success was achieved in 22 of 26 procedures (84.6%). Guiding catheters facilitated selective cannulation in 20 of 22 cases (90.9%), with failures occurring exclusively in patients with Whipple anatomy. Controlled radial expansion (CRE) balloons were required in 4 patients; although all strictures were successfully dilated (100%), selective biliary cannulation was obtained in only 2 of these cases (50%) (Table 2).\u003c/p\u003e\n\u003cp\u003eThe mean procedure time was 89 \u0026plusmn; 32 minutes. Procedures in patients with Roux-en-Y hepaticojejunostomy required significantly longer times than those with choledochojejunostomy (102 \u0026plusmn; 28 vs. 78 \u0026plusmn; 24 minutes, \u003cem\u003ep\u003c/em\u003e = 0.03), reflecting the complexity of navigating long afferent limbs (Table 3). Fluoroscopy times showed a similar trend (18 \u0026plusmn; 6 vs. 14 \u0026plusmn; 5 minutes), though this difference did not reach statistical significance (\u003cem\u003ep\u003c/em\u003e = 0.12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical success was achieved in 22 patients (84.6%). Serum bilirubin decreased significantly from 5.4 \u0026plusmn; 3.1 mg/dL at baseline to 1.2 \u0026plusmn; 0.7 mg/dL at 4 weeks (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). In parallel, liver enzymes normalized, with ALT declining to 38 \u0026plusmn; 28 U/L and alkaline phosphatase to 220 \u0026plusmn; 180 U/L (both \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) (Table 4).\u003c/p\u003e\n\u003cp\u003eWhen contextualized with international data (Table 5), our outcomes are comparable to those reported from high-resource centers using short DBE systems, such as Itoi et al. (94% success, 9% complications) and Khashab et al. (89% success, 11% complications). Importantly, our success rate aligns closely with the pooled rates summarized by Tanisaka et al. (87\u0026ndash;93%), underscoring the feasibility of long DBE even in settings without short enteroscopes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdverse events occurred in 3 patients (11.5%). Two developed mild post-procedure Cholangitis, both managed with a short-course third-generation quinolone regimen, and one experienced self-limited bleeding following CRE dilatation that was controlled endoscopically. No perforations, severe bleeding, pancreatitis, or procedure-related deaths were observed.\u003c/p\u003e\n\u003cp\u003eAmong the 4 technical failures, alternative drainage methods were pursued, including endoscopic ultrasound-guided hepaticogastrostomy (\u003cem\u003en\u003c/em\u003e = 1), percutaneous transhepatic biliary drainage (\u003cem\u003en\u003c/em\u003e = 1), and the Randex Voux technique (\u003cem\u003en\u003c/em\u003e = 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis multicenter prospective study demonstrates that long DBE combined with guiding catheter techniques is both feasible and effective for biliary access in patients with surgically altered anatomy (SAA). Our technical and clinical success rate of 84.6% is comparable to outcomes reported from high-resource centers employing short DBE systems, where success rates typically exceed 85\u0026ndash;90% [2,3,17]. Similarly, our overall adverse event rate of 11.5% is consistent with the pooled data summarized by Tanisaka et al., who reported success rates of 87\u0026ndash;93% and complication rates of 7\u0026ndash;12% across multiple international studies [19]. Taken together, these findings underscore that long DBE, when supplemented with tailored technical modifications, can provide therapeutic outcomes on par with advanced centers, even in resource-limited settings.\u003c/p\u003e\n\u003cp\u003eProcedural duration varied significantly by anatomy, with Roux-en-Y cases requiring longer times compared with choledochojejunostomies. This reflects the inherent challenges of long afferent limb navigation, including looping, sharp angulations, and scope instability. Loop reduction maneuvers, careful fluoroscopic guidance, and effective two-operator coordination were critical to achieving success in these cases, as highlighted in prior device-assisted enteroscopy studies [11,12]. The extended fluoroscopy times observed in Roux-en-Y cases, although not statistically significant, further emphasize the technical demands of this anatomy.\u003c/p\u003e\n\u003cp\u003eTechnical Innovations\u003c/p\u003e\n\u003cp\u003eThe adoption of guiding catheters played a pivotal role in overcoming the intrinsic limitations of long enteroscopes, particularly their restricted accessory length. By facilitating stable guidewire passage, reliable contrast injection, and controlled stent deployment, the guiding catheter significantly increased procedural success. The \u0026ldquo;stent-in-catheter\u0026rdquo; method, applied in five patients, proved especially practical, allowing for precise stent placement without the need for specialized short-scope accessories. Similarly, controlled radial expansion (CRE) balloons were effective for stricture dilation, though their role in primary biliary cannulation was limited, consistent with prior reports [21]. These adaptations highlight the value of simple, reproducible techniques that expand the therapeutic potential of long DBE in environments where short enteroscopes and specialized accessories are not available.\u003c/p\u003e\n\u003cp\u003eOur results reinforce the clinical relevance of long DBE as a viable alternative to short DBE or more invasive modalities in SAA patients. In the absence of short enteroscopes, reliance on percutaneous or surgical drainage has historically been high, often associated with greater morbidity and reduced patient comfort [22]. By demonstrating comparable outcomes with long DBE, our study provides evidence that safe, effective endoscopic therapy can be delivered in low-resource settings without compromising success or safety. This has important implications for global endoscopy practice, particularly in regions where healthcare systems face significant equipment and cost.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Study Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. The overall cohort size was modest, particularly with respect to patients who had undergone Whipple surgery, in whom most technical failures were observed. The relatively short follow-up period also precludes a comprehensive evaluation of long-term outcomes, including the durability of stricture dilatation, stent patency, and the risk of recurrent obstruction. Nevertheless, despite these constraints, this work represents one of the largest prospective series to date assessing the role of long double-balloon enteroscopy for biliary access in surgically altered anatomy within a resource-limited setting.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLong DBE with guiding catheter-assisted cannulation achieves effective biliary access in SAA, with outcomes comparable to high-resource settings and acceptable safety. This approach is a cost-effective, practical solution for resource-limited centers. Larger multicenter studies are needed for validation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors did not have any conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGhoneem Elsayed, Abou Taleb Hani, and Yousif Abdo Ahmed designed and organized this study, wrote the manuscript, and reviewed the patient data. Yousif Abdo Ahmed, Ahmed Yasmine, and Muhammed Abdelghaffar enrolled patients, collected detailed data, and reviewed the paper. Ahmed Yasmine reviewed the radiological assessment of the patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Transparency Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient data used to support the findings of this study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No financial support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- Study design and drafting: Elsayed Ghoneem, Hani Abou Taleb, Ahmed Abdo Yousif\u003c/p\u003e\n\u003cp\u003e- Data collection: Ahmed Abdo Yousif, Muhammed Abdelghaffar, Yasmine Ahmed\u003c/p\u003e\n\u003cp\u003e- Radiology review: Yasmine Ahmed\u003c/p\u003e\n\u003cp\u003e- All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e Available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eItoi T, Ishii K, Tanaka R, et al. Long- versus short-type double-balloon enteroscopy for therapeutic ERCP in patients with surgically altered anatomy: systematic review and meta-analysis. Gastrointest Endosc. 2021;93(4):890\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNabi Z, Reddy DN. Endoscopic management of biliary issues in patients with surgically altered anatomy. Gastrointest Endosc Clin N Am. 2022;32(1):157\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkinner M, Popov V, Pleskow D. ERCP in surgically altered anatomy: how we do it. Clin Gastroenterol Hepatol. 2021;19(5):892\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLenze F, Nowacki TM, Beyna T, et al. Enteroscopy in the management of biliary tract disease in patients with surgically altered anatomy: a systematic review and meta-analysis. Gastrointest Endosc. 2020;91(2):312\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah RJ, Smolkin M, Yen R, et al. A multicenter U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy. Gastrointest Endosc. 2017;85(3):483\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsujino T, Katanuma A, Kawakami H. Double-balloon enteroscopy-assisted ERCP in patients with surgically altered anatomy: tips and tricks. Gastrointest Endosc. 2020;92(1):47\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatanuma A, Matsumori T, Hayashi T, et al. Techniques of device-assisted enteroscopy for ERCP in altered gastrointestinal anatomy. Dig Endosc. 2022;34(2):199\u0026ndash;214.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgura T, Higuchi K. Technical tips and recent development of endoscopic ultrasound-guided hepaticogastrostomy. Dig Endosc. 2022;34(1):50\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTyberg A, Desai AP, Kumta NA, et al. EUS-guided biliary drainage after failed ERCP: a novel algorithm individualized to patient anatomy. Gastrointest Endosc. 2021;93(4):859\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):17\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eASGE Technology Committee, Enteroscopy. Gastrointest Endosc. 2021;93(5):1095\u0026ndash;113.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark TY, Choi JS, Oh HC, et al. Preoperative MRCP to plan endoscopic interventions in patients with surgically altered anatomy: does it help? Clin Radiol. 2021;76(3):215\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanisaka Y, Mizuide M, Fujita A, et al. Balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. Int J Gastrointest Interv. 2021;10(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhashab MA, Bukhari M, Baron TH, et al. International multicenter comparative trial of transluminal EUS-guided biliary drainage versus hepatogastrostomy for malignant distal biliary obstruction. Endosc Int Open. 2020;8(6):E751\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKunda R, P\u0026eacute;rez-Miranda M, Will U, et al. EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after failed ERCP: a multicenter international collaborative study. Surg Endosc. 2022;36(8):5678\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71(3):446\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkinner M, Gutierrez JP, Neumann H, et al. ERCP with the short double-balloon enteroscope: a multicenter U.S. experience. Gastrointest Endosc. 2014;80(4):717\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoreels TG. Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. Curr Opin Gastroenterol. 2017;33(5):324\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanisaka Y, Mizuide M, Fujita A, et al. Balloon enteroscope-assisted ERCP in patients with surgically altered anatomy: a comprehensive review. Int J Gastrointest Interv. 2021;10(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInoue T, Okumura F, Sano H, et al. A new cannulation technique using a double-guidewire method in balloon enteroscopy-assisted ERCP. Endoscopy. 2021;53(2):E103\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanno Y, Ito K, Koshita S, et al. Usefulness of catheter-assisted cannulation in difficult biliary access during balloon enteroscopy-assisted ERCP. Endosc Int Open. 2019;7(11):E1449\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngsuwatcharakon P, Rerknimitr R, Kullavanijaya P, et al. Outcome of endoscopic retrograde cholangiopancreatography in patients with altered anatomy. World J Gastroenterol. 2010;16(38):4695\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u0026nbsp; \u0026nbsp;\u003cstrong\u003eTable 1: Baseline Demographics and Clinical Features:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"522\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue (n=26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e49.5 \u0026plusmn; 11.2 (20-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eMale gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e10 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eSurgical Anatomy:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Roux-en-Y hepaticojejunostomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Choledochojejunostomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Whipple procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (53.8%)\u003c/p\u003e\n \u003cp\u003e9 (34.6%)\u003c/p\u003e\n \u003cp\u003e3 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eTime since surgery (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e28.4 \u0026plusmn; 18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eLaboratory Values:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Total bilirubin (mg/dL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Direct bilirubin (mg/dL)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Alkaline phosphatase (U/L)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; GGT (U/L)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;ALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.4 \u0026plusmn; 3.1\u003c/p\u003e\n \u003cp\u003e4.2 \u0026plusmn; 2.8\u003c/p\u003e\n \u003cp\u003e988 \u0026plusmn; 650\u003c/p\u003e\n \u003cp\u003e295 \u0026plusmn; 280\u003c/p\u003e\n \u003cp\u003e98 \u0026plusmn; 85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Procedure Outcomes, Technical Success by Anatomy Type:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe Altered Anatomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReach Success\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCannulation Success\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGuiding Catheter Used\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRE Balloon Used\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eRoux-en-Y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e14 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e12 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e12 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e2 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eCholedochojejunostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e8 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e8 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e1 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eWhipple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e26 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e22 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e22 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e4 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Overall cannulation success: 84.6% (22/26)\u003c/p\u003e\n\u003cp\u003eGuiding catheter success: 90.9% (20/22), while CRE balloon success: 50% (2/4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure Characteristics:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Mean procedure time is 89 \u0026plusmn; 32 minutes: In cases with Roux-en-Y: 102 \u0026plusmn; 28 min while in Choledochojejunostomy cases it is 78 \u0026plusmn; 24 min (p=0.03)\u003c/p\u003e\n\u003cp\u003e*Mean fluoroscopy time: 16 \u0026plusmn; 7 minutes\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Detailed Procedure Outcomes by Anatomy Type:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRoux-en-Y (n=14)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCholedochojejunostomy (n=9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhipple (n=3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eMean procedure time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e102 \u0026plusmn; 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e78 \u0026plusmn; 24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e95 \u0026plusmn; 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eFluoroscopy time(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e18 \u0026plusmn; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e14 \u0026plusmn; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e17 \u0026plusmn; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eStricture dilation needed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e9 (64.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e5 (55.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e2 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eStent placement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e12 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e7 (77.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e2 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Clinical and Laboratory Post-Procedure Outcomes:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-Procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Week\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 Weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eTotal bilirubin (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e5.4 \u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.2 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e98 \u0026plusmn; 85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e45 \u0026plusmn; 32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e38 \u0026plusmn; 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAlkaline phosphatase (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e988 \u0026plusmn; 650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e450 \u0026plusmn; 320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e220 \u0026plusmn; 180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*Post-procedure related complications were 11.5%.\u0026nbsp;\u003c/strong\u003eMild cholangitis developed in 2 cases (7.7%), and self-limited bleeding in 1 case (3.8%). No perforations or mortality encountered.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Comparison with Global studies Outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScope Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccess Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCurrent study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eLong DBE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e84.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e11.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eItoi et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eJapan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eShort DBE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e94%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eKhashab et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eShort DBE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e89%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eRahman et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eBangladesh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eLong DBE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e78%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eTanisaka et al. (Review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eJapan (multicenter)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eEnteroscopy-assisted ERCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e87\u0026ndash;93%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e7\u0026ndash;12%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Enteroscopy, biliary stricture, Roux-en-Y, resource-limited, ERCP","lastPublishedDoi":"10.21203/rs.3.rs-8560756/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8560756/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Aims:\u003c/h2\u003e \u003cp\u003eBiliary obstruction in patients with surgically altered anatomy (SAA) poses significant challenges, particularly in resource-limited settings lacking short enteroscopes. This study evaluated the efficacy and safety of long double-balloon enteroscopy (DBE) with long guiding catheters and controlled radial expansion (CRE) balloons for biliary access.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eBetween January 2021 and December 2023, 26 consecutive SAA patients with biliary obstruction underwent therapeutic long DBE at three tertiary centers in Egypt. The primary outcomes were technical success (defined as anastomosis reach and successful cannulation) and clinical success (defined as bilirubin normalization at 4 weeks). Secondary outcomes included procedure characteristics, complications, and the need for alternative interventions.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eTechnical success was achieved in 84.6% (22/26). Mean procedure time was 89\u0026thinsp;\u0026plusmn;\u0026thinsp;32 minutes, with Roux-en-Y hepaticojejunostomy cases requiring longer times than choledochojejunostomy (102\u0026thinsp;\u0026plusmn;\u0026thinsp;28 vs. 78\u0026thinsp;\u0026plusmn;\u0026thinsp;24 min, p\u0026thinsp;=\u0026thinsp;0.03). Bilirubin decreased significantly from 5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 to 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 mg/dL at 4 weeks (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Complications occurred in 11.5% (3/26): two mild cholangitis and one self-limited bleeding. Four failures required alternative interventions (EUS-guided hepaticogastrostomy, percutaneous drainage, or Randex Voux technique).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eLong DBE with long guiding catheters enables effective biliary access in SAA patients, achieving outcomes comparable to high-resource settings. This strategy represents a practical solution for centers lacking short enteroscopes.\u003c/p\u003e","manuscriptTitle":"Long Double-Balloon Enteroscopy for Biliary Access in Surgically Altered Anatomy: Outcomes and Technical Adaptations in Resource-Limited Settings","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 16:53:01","doi":"10.21203/rs.3.rs-8560756/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"120503655939424414089040978334641259324","date":"2026-04-29T04:58:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T02:04:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144805868947995954334388149966993395373","date":"2026-04-29T01:01:36+00:00","index":"hide","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-24T21:16:42+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-10T12:46:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T10:20:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-13T10:16:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2026-01-09T11:45:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c8d1a16d-fc46-4dd8-9e83-2272e627fa71","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-13T16:53:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 16:53:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8560756","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8560756","identity":"rs-8560756","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}