Double balloon endoscopy for pancreatic and biliary access in altered anatomy (with videos).

BACKGROUND: Access to the papilla of Vater or enteral anastomoses to the biliary tract or pancreatic duct is difficult in patients with altered anatomy. The usual approach to the papilla of Vater with a side-viewing duodenoscope, designed for passage through the stomach, pyloric channel, and proximal duodenum, is not suitable in postoperative patients with challenging anatomic rearrangements. There is therefore a need for better instrumentation to achieve access in patients with difficult anatomy.

OBJECTIVE: To assess the potential of the new double balloon endoscope system for use in difficult postsurgical anatomic configurations. This system has now been utilized in several of these types of anatomic rearrangements with successful access to the papilla of Vater and hepatico-jejunal, choledocho-jejunal, or pancreatico-jejunal anastomoses. The technique of advancing the system and achieving cannulation is described. The accessories necessary and therapeutic potential are addressed.

INTERVENTIONS: Diagnostic and therapeutic management of pancreatic and biliary disorders in altered anatomy.

CONCLUSION: Double balloon enteroscopy has provided a means to access the stomach, duodenum, biliary tract, and pancreatic duct after surgical procedures that have made access by the usual routes with the usual instruments not possible.