Efficacy and safety of double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in surgically altered anatomy: A systematic review and meta-analysis

Table 3 Patient characteristics

Ref.	Study design	Period	Country	n	Age	Female (%)	Patient anatomy	Inclusion criteria
Aabakken et al[34]	Retrospective case series	2005-2006	Norway	18 procedures in 13 patients	53 (2-81)	31	Roux-en-Y (n = 13)	Patients who underwent DBE-ERCP procedures with RY anatomy
Emmett and Mallat[35]	Retrospective case series	2005-2007	United States	20 procedures in 14 patients	47 (27-73)	50	RYGB (n = 6), PD (n = 4), Liver transplant with HJ (n = 1), Liver transplant with CJ (n = 1), PJ (n = 1), Frey procedure (n = 1)	Patients who had previously had a RYGI, RY Whipple resection with PJ, orthotropic liver transplantation with HJ or CJ, or a Frey procedure who underwent ERCP
Maaser et al[36]	Retrospective case series	2004-2007	Germany	11 procedures in 11 patients	62.8 (30-78)	27	Partial gastrectomy with GI and RY (n = 1), Partial gastrectomy with GI and RY and CD (n = 1), Total gastrectomy with RY (n = 1), Partial gastrectomy with Billroth II GI (n = 2), PD (n = 3), Pylorus-preserving CJ with RY (n = 2), RYHJ (n = 1), Duodenum-preserving pancreatic head resection in combination with CJ (n = 1)	Patients with various anatomic variations in whom DBE-ERCP was performed
Mönkemüller et al[37]	Prospective cohort study	-	Germany	11 procedures in 11 patients	59 (36-77)	9	RYHJ (n = 11)	Patients with RY anastomosis and pancreaticobiliary problems who underwent DBE-ERCP
Moreels et al[38]	Retrospective case series	2006-2008	Belgium	15 procedures	-	-	Roux-en-Y entero-enteric anastomosis	Patients who underwent DBE-ERCP for suspected pathology in the excluded gastrointestinal segment or in the biliopancreatic system after Roux-en-Y entero-enteric anastomosis
Pohl et al[39]	Retrospective case series	2004-2008	Germany	25 procedures in 15 patients	60.2 (25-80)	27	RYCJ (n = 15)	Patients with CJ anastomosis who underwent DBE-ERCP procedures
Shimatani et al[25]	Retrospective case series	2006-2008	Japan	68 procedures in 36 patients	-		RY total gastrectomy (n = 36), Billroth II gastrectomy (n = 17), PD (n = 15)	Patients with pancreaticobiliary disease and previous bowel reconstruction undergoing DBE-ERCP at a single center between January 2006 and December 2008
Parlak et al[40]	Retrospective case series	2006-2008	Turkey	14 procedures in 14 patients	45.3 (28-61)	54	RYHJ (n = 14)	Patients with RYHI who underwent ERCP
Cho et al[41]	Retrospective cohort study	2007-2008	Canada	29 procedures in 20 patients	57.9 (26-85)	50	RYHJ (n = 7), Billroth II (n = 6), RYGJ (n = 5), RYEJ (n = 1), PD with CJ (n = 1)	Patients with small-bowel reconstruction who underwent ERCP using a short DBE
Mönkemüller et al[42]	Retrospective case series	-	Germany	23 procedures in 18 patients	-	-	RYHJ (n = 18)	Patients who underwent DBE-ERCP procedures with Roux-en-Y hepaticojejunostomy
Raithel et al[43]	Prospective case series	2005-2008	Germany	86 procedures in 31 patients	61 (38-84)	54.8	Roux-en-Y reconstruction (n = 30), End-to-side gastrojejunostomy (n = 1)	Patients who underwent DBE-ERCP for pancreatobiliary diseases after complex abdominal anatomy (e.g., Billroth II, Whipple, Roux-en-Y)
Chua and Kaffes[44]	Retrospective case series	2008-2011	Australia	18 procedures in 16 patients	-	-	-	Patients who underwent DBE-ERCP procedures with surgically altered anatomy
Osoegawa et al[45]	Retrospective case series	2006-2011	Japan	47 procedures in 28 patients	74 (54-91)	35.7	Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), Roux-en-Y anastomosis with PD (n = 2)	Patients who underwent DBE-ERCP for pancreatobiliary diseases after bowel reconstruction
Siddiqui et al[46]	Retrospective case series	2008-2011	United States	79 procedures in 79 patients	78 (29-86)	62	RYGB (n = 39), Billroth II (n = 3), PD (n = 20), HJ (n = 3), RYHJ (n = 4), RYGJ (n = 5), CJ (n = 2), RYPJ (n = 3)	Patients with various anatomic variations in whom ERCP was performed using short DBE
Shah et al[8]	Retrospective case series	2008-2009	United States	27 procedures in 27 patients	-	-	RYGB (n = 15), Non-RYGB including HJ, Whipple resection, other (n = 12)	Long-limb surgical bypass patients with suspected pancreatobiliary diseases
Varabei et al[47]	Retrospective case series	2009-2012	Belarus	33 procedures in 33 patients	53.7 (38-69)	76	RYHJ, jejunum loop with Braun bypass (n = NR)	Patients with RYHJ anastomoses and jejunum loop with Braun's bypass anastomosis who underwent DBE-ERCP
Cheng et al[26]	Retrospective cohort study	2006-2013	Taiwan	77 procedures in 77 patients	76 (50-95)	24	Billroth II (n = 77)	Patients with B2 gastrectomy in whom standard ERCP failed
Sakakihara et al[48]	Retrospective case series	2008-2012	Japan	44 procedures in 44 patients	63.5 ± 14.0	38.6	Modified Child’s method (n = 27) Roux-en Y reconstruction (n = 17)	Patients who underwent DBE-ERCP procedures with stenosis of choledochojejunal anastomosis
Tsou et al[58]	Retrospective cohort study	2007-2013	Taiwan	47 procedures in 47 patients	54.4 (26-87)	53	RY (n = 47)	Patients with RY anastomosis who underwent DBE-ERC
Tsutsumi et al[49]	Retrospective case series	2007-2013	Japan	72 procedures in 72 patients	69 (37-83)	39	PD (n = 72)	Patients with prior PD including SSPPD and PPPD who underwent attempted diagnostic or therapeutic ERCP
De Koning and Moreels[6]	Retrospective case series	2006-2012	Belgium	30 procedures in 10 patients	60 (30-76)	50	Short-limb RY (< 50 cm) with bilioenteric anastomosis (Whipple or BD) (n = 24), Short-limb RY (< 50 cm) with intact papilla (total gastrectomy) (n = 2), Long-limb RY (> 100 cm) with intact papilla (Scopinaro, GB) (n = 4)	Consecutive patients with RY altered small-bowel anatomy undergoing balloon-assisted ERCP performed by a single endoscopist in a single center
Shimatani et al[50]	Prospective case series	2013-2014	Japan	311 procedures in 311 patients	67.3 (14.6)	32.5	RY (n = 203), Billroth II (n = 26), PD (n = 44), PPPD (n = 31), Others (n = 7)	Consecutive patients above the age of 20 with altered GI anatomies and suspected biliary disease who were referred to eight institutions between June 2013 and May 2014
Tomoda et al[59]	Retrospective cohort study	2001-2014	Japan	20 procedures in 20 patients	50.85 (5-74)	35	RYHJ (n = 18), Not specified (n = 2)	Patients who underwent ERCP using a short DBE upon suspicion of biliary stricture after living donor liver transplantation with HJ reconstruction
Liu et al[60]	Retrospective cohort study	2009-2015	Australia	86 procedures in 52 patients	60.5 (18-89)	25	RYHJ (n = 42), RY with GJ (n = 9)	Patients with RY anastomosis who underwent a DBE-ERCP
Shimatani et al[7]	Retrospective case series	2015-2016	Japan	112 procedures in 100 patients	61.6 (18.2)	64.6	RYHJ (n = 30), RY partial gastrectomy (n = 17), RY total gastrectomy (n = 17), Billroth II gastrectomy (n = 8), PD (n = 13), PPPD (n = 12), Billroth II and RY (n = 1), GJ (n = 1), Jejunal pouch interposition (n = 1)	Procedures performed using new short-type DBE (N-short DBE) in postoperative patients at a single center between August 2015 and April 2016
Tsutsumi et al[61]	Prospective cohort study	2014-2017	Japan	33 procedures in 33 patients	65 (53-73)	56	RYHJ (n = 33)	Patients with suspected biliary diseases who had RYHI with side-to-end jejunojejunostomy
Kashani et al[31]	Retrospective case series	2005-2012	United States	129 procedures in 103 patients	50 (22-82)	87	RYGB (n = 103)	Patients with a history of RYGB who underwent DBE-ERCP
Matsumoto et al[51]	Retrospective case series	2010-2016	Japan	11 procedures in 11 patients	71 (53-74)	37	Child's reconstruction (n = 4) Roux-en-Y (n = 7)	Patients with HJ who underwent DBE-ERC for postoperative bile leakage
Mizukawa et al[62]	Retrospective cohort study	2008-2014	Japan	46 procedures in 46 patients	69 (64-75)	41	PD with Braun anastomosis (n = 29), PD without Braun anastomosis (n = 1), PPPD with Braun anastomosis (n = 12), SSPPD (n = 4)	Patients with suspected benign HJ anastomotic stricture after Whipple's procedure who underwent diagnostic ERCP using a short DBE
Yamada et al[63]	Prospective cohort study	2005-2017	Japan	326 procedures in 326 patients	64.9 (15.5) (EI-580BT cohort)	56	PD without Braun anastomosis (n = 1), PPPD with Braun anastomosis (n = 12), SSPPD (n = 4), Gastrectomy with Billroth II (n = 29), Gastrectomy with RY (n = 82), PD with Billroth II (n = 53), PD with RY (n = 42), RYHJ (n = 96), Liver transplantation with HJ (n = 20)	Patients with surgically altered anatomy that underwent ERCP using double-balloon endoscopy with the EI-580BT or EI-530B endoscope
Nishio et al[52]	Retrospective case series	2011-2018	Japan	104 procedures in 66 patients	70 (66.3-75.8) in the LO group; 67 (61-74) in the control group	44	Liver operation group: Hepatectomy (n = 14), and LDLT (n = 12), Control group: PD (n = 9), PPPD (n = 4), SSPPD (n = 27)	Patients who underwent DBE-ERCP after hepatectomy or LDLT (LO group); Patients who underwent DB-ERCP after pancreatoduodenectomy (control group)
Sato et al[53]	Retrospective case series	2008-2018	Japan	102 procedures in 102 patients	69 (22-84)	40	Roux-en-Y (n = 80), Billroth-II (n = 22)	Patients who underwent DBE-ERCP procedures with Roux-en-Y or Billroth-II for Hepaticojejunostomy anastomotic stricture
Sirin and Hulagu[54]	Retrospective case series	2008-2014	Japan	31 procedures in 31 patients	-	34	Billroth II with long afferenf limb (n = 8), Billroth II with acute angle of anastomosis of the afferent limb (n = 6), Billroth II with R-en-Y (n = 6), RYHJ (n = 11)	Patients with BII gastrojejunostomy and hepaticojejunostomy (with or without Roux-en-Y) who underwent DBE-ERCP during the same session due to failure of standard ERCP using standard duodenoscope
Uchida et al[32]	Retrospective case series	2011-2018	Japan	805 procedures in 319 patients	Median 69 years	38.9	Modified Child method after SSPPD (n = 133), modified Child method after PPPD (n = 29), Roux-en-Y with choledochojejunal anastomosis (n = 116), Roux-en-Y without choledochojejunal anastomosis (n = 19), Billroth II (n = 22)	Patients who underwent DBE-ERCP procedures with surgically altered gastrointestinal anatomy
Zamora Nava et al[64]	Prospective cohort study	2010-2016	Mexico	96 procedures in 75 patients	40.8 ± 10.2	71.9	RYHJ (n = 79), PD (n = 10), Billroth II (n = 3), Gastric bypass (n = 2), Esophagus jejunum anastomosis (Roux-en-Y) (n = 2)	Patients who underwent DBE-ERCP after Predominantly Roux-en-Y hepaticojejunostomy
CHENG et al[55]	Retrospective case series	2015-2020	Hong Kong SAR, China	46 procedures in 37 patients	70.8 ± 15.6	43.2	Billroth II (n = 15), Roux-en-Y (n = 10), RYHJ (n = 5), PD (n = 6), Portoenterostomy (Kasai Operation) (n = 1)	Patients who underwent DB-EERCP with biliary diseases
Obata et al[56]	Retrospective case series	2011-2020	Japan	79 procedures in 79 patients	79 (73-84)	22	Roux-en-Y Gastrectomy (n = 79)	Patients who underwent DB-EERCP procedures with Roux-en-Y for CBD stones
Sato et al[57]	Retrospective case series	2017-2019	Japan	20 procedures in 20 patients	73 (60-75)	45	PD with Billroth-II (n = 10), PD with Roux-en-Y (n = 4), Resection of the extrahepatic bile duct with Roux-en-Y (n = 5), Total pancreatectomy with Billroth-II (n = 1)	Patients who underwent DB-EERCP procedures with HJASs or who were unamenable to balloon dilation or prior plastic stent placement
Farina et al[65]	Retrospective cohort study	2013-2021	Italy	53 procedures in 53 patients	65 (23-89)	40	Pancreaticoduodenectomy (n = 9), Roux-en-Y gastrectomy (n = 17), Roux-en-Y biliodigestive anastomosis (n = 24), Billroth II gastrectomy (n = 3)	Patients who underwent DB-EERCP with post-surgical biliary disorders
Yokoyama et al[66]	Retrospective cohort study	2007-2022	Japan	289 procedures in 289 patients	-	-	RYG (TG) (n = 88), RYG (DG) (n = 33), Cardiac gastrectomy (n = 1), Billroth II (n = 33), RYHJ (n = 38), PD (n = 29), RYLT (n = 35)	Patients who underwent DB-EERCP procedures with SAA treated for biliary stones

ERCP: Endoscopic retrograde cholangiopancreatography; DBE-ERCP: Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography; RYHJ: Roux-en-Y hepaticojejunostomy; RYGB: Roux-en-Y gastric bypass; RY: Roux-en-Y; HJ: Hepaticojejunostomy; CJ: Choledochojejunostomy; PJ: Pancreaticojejunostomy; GI: Gastrointestinal (or gastrojejunostomy); GJ: Gastrojejunostomy; CD: Choledochoduodenostomy; PD: Pancreaticoduodenectomy; RYCJ: Roux-en-Y choledochojejunostomy; RYEJ: Roux-en-Y esophagojejunostomy; RYGJ: Roux-en-Y gastrojejunostomy; RYPJ: Roux-en-Y pancreaticojejunostomy; RYGI: Roux-en-Y gastrointestinal reconstruction; PPPD: Pylorus-preserving pancreaticoduodenectomy; SSPPD: Subtotal stomach-preserving pancreaticoduodenectomy; LDLT: Living donor liver transplantation.