Endoscopic treatment for the surgically altered anatomical case is still challenging. Because of long afferent limb with adhesion may obstruct endoscopic insertion. Subsequent biliary and pancreatic canulation is also difficult; difficult to locate the scope as face to the papilla and to cannulate with different direction using non-dedicated scope for ERCP.
Scope selection is important according to the reconstruction; Billroth 1, 2 and Rou-en-Y. Standard duodenoscope is available in B-1 and B-2. Forward viewing scope is useful to reach to the papilla safely in B-2 but cannulation is more difficult than duodenoscope. Balloon-assisted endoscopy (BAE) is useful to reach to the papilla in the cases with B-2 and R-Y reconstruction.
There were some difficulties in this procedure with BAE; cannulation to both papilla and anastomosis, sphincterotomy, removal of stone and place the stent. The devices are limited by the size of scope channel, and the scope maneuver is also limited compare to the duodenal scope. We ordinary perform EPBD or EPLBD without sphincterotomy to remove the stones. Balloon dilation is simple and easy to open the papilla, and considered as effective and safety procedure. Stricture of anastomosis is other indication, causes recurrent cholangitis and intrahepatic stones. We also dilate the stricture with balloon, remove the stones and place the stent. Sometimes, the stricture caused due to tumor recurrence. We can diagnose the cause of stricture and place the stent with BAE.
Recent development of Interventional EUS, we can perform both stone extraction and drainage. The advantage of Interventional EUS is short procedure time and relatively easy approach to the biliary and pancreatic duct. Lack of dedicated devices, difficult to approach to the right intra-hepatic bile duct, difficult puncture of non-dilated duct and possible severe adverse events such as perforation and peritonitis were disadvantages of Intervention EUS.