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

Table 4 Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography characteristics

Ref.	Type of double balloon ERCP	Duration of procedure (minutes)	Indication for ERCP	Therapeutic intervention conducted
Aabakken et al[34]	Long (EN-450 T5, 200 cm)	40 (5-120)		Stent removal (n = 3)
Emmett and Mallat[35]	Long (200 cm)	99 (51-147)	Abnormal LFTs (n = 4), Acute pancreatitis (n = 1), Chronic pancreatitis (n = 2), Cholangitis (n = 2), Recurrent pancreaticobiliary pain (n = 5), Repeat procedure/follow-up (n = 6)	Stone extraction (n = 1), Biliary duct dilation (n = 1), Biliary duct sphincterotomy (n = 2), Biliary duct stent placement (n = 1), Pancreatic duct dilation (n = 1), Pancreatic duct sphincterotomy (n = 1), Pancreatic duct stent placement (n = 1), Pancreatic duct stent removal (n = 1)
Maaser et al[36]	Long (EN-450P5 or EN-450T5, 200 cm)		Choledocholithiasis (n = 1), Cholangitis (n = 4), Biliary pancreatitis (n = 1)	Sphincterotomy (n = 4), Stone extraction (n = 1), Dilation of anastomotic stricture (n = 1)
Mönkemüller et al[37]	Long (EN-450T5, 200 cm)	70 (45-120)	Jaundice (n = 2), Cholestasis (n = 6), Stent extraction (n = 1), CBD-stenosis (n = 1), Choledocolithiasis (n = 1)	Sphincterotomy (n = 2), papillectomy (n = 1), biliary stent insertion (n = 5), dilation of CBD stenosis with a balloon (n = 4), stone removal (n = 2), and stent retrieval (n = 5)
Moreels et al[38]	Long (EN-450T5, 200 cm)	-	Biliopancreatic pathology (15 procedures), unexplained abdominal pain after gastric bypass (9 procedures), suspected small bowel bleeding or abdominal pain after gastrectomy (4 procedures), enterocutaneous fistula closure (2 procedures)	For biliopancreatic pathology: Cholangiography, balloon dilation, stone extraction, stent placement for unexplained abdominal pain after gastric bypass: Gastric mucosa biopsy. For suspected small bowel bleeding or abdominal pain after gastrectomy: Enteroscopy and mucosal inspection. For enterocutaneous fistula closure: Closure using cyanoacrylate surgical glue and rotatable clip devices
Pohl et al[39]	Long (EN-450T5, 200 cm)	74.6 (49.6-99.6)	Evaluation of jaundice or suspected (n = 14), Biliary obstruction with pain considered to be of biliary origin (n = 1), Biliary obstruction with bleeding (n = 1)	Stone extraction (n = 5), Biliary duct dilation (n = 11), Biliary duct stent placement (n = 3)
Shimatani et al[25]	Short (EC-450BI5, 152 cm)	-	-	Stone extraction (n = 47), Nasobiliary drainage (n = 38), Stent placement (n = 36), Sphincterotomy (n = 31), Choledochojejunostomy dilation (n = 29), Tumor biopsy (n = 10), Nasopancreatic duct drainage (n = 1)
Parlak et al[40]	Long (EN-450T5, 200 cm)	75 (13-137)	Biliary obstruction (n = 11), Cholangitis (n = 9), Stent change (n = 7), Anastomotic stenosis on percutaneous Cholangiogram (n = 1), Jaundice (n = 2), Itching (n = 1)	Stent removal (n = 5), Extraction of catheter (n = 16), Stent placement (n = 10), Stent removal (n = 4), Balloon dilation (n = 1), Stricturoplasty with needle (n = 1)
Cho et al[41]	Short (EC-450BI5, 152 cm)	70.7 (30-117)	Choledocholithiasis (n = 10), Stricture (n = 8), Cholangitis (n = 8), Follow-up ERCP (n = 2), Bile leakage (n = 1)	Sphincterotomy (n = 7), Balloon dilation of biliary sphincter (n = 4), Stone extraction (n = 9), Biliary stricture dilation (n = 8), Stent placement (n = 9), Stent removal (n = 8)
Mönkemüller et al[42]	Long (EN-450T5, 200 cm)	70 (35-240)	Jaundice (n = 3) Cholestasis (n = 7) Choledocolithiasis (n = 4), Cholangitis (n = 3) Upper GI-bleeding (n = 1)	Biliary stent insertion, dilation of common bile duct stenosis with a balloon, stone removal with Dormia basket, stent retrieval
Raithel et al[43]	Long (EN-450T5, 200 cm)	-	Cholestasis, Cholangitis, Choledocholithiasis, Presence of a pancreatic pseudocyst, Suspected or advanced chronic pancreatitis	radiograph the bile ducts (n = 28) Radiography of the pancreatic duct (n = 1)
Chua and Kaffes[44]	Long (EN-450T5, 200 cm)	-	Biliary stenosis (n = 12) Choledocholithiasis (n = 3), Others (n = 1)	Stent removal, stricture dilatation, stone removal with a biliary extraction balloon, plastic stent insertion
Osoegawa et al[45]	Short (EC-450BI5, 152 cm)	93.6 ± 6.8	Pancreatobiliary diseases	Endoscopic biliary drainage (n = 24), Stone extraction (n = 14), Endoscopic sphincterotomy (n = 14), Balloon dilation (n = 10)
Siddiqui et al[46]	Short (EC-450BI5, 152 cm)		Removal of a previously placed stent (n = 5), Sphincter of Oddi dysfunction (n = 3), Surgical biliary leak (n = 3), Pancreatic anastomotic stricture (n = 2), suspected Choledocholithiasis (n = 48), Biliary strictures (n = 18)	Biliary sphincterotomy (n = 39), Dilation of CBD stenosis with a balloon (n = 30), Stent placement (n = 25), Stone extraction (n = 35), Brushing cytology of biliary strictures (n = 3), Stent removal (n = 4)
Shah et al[8]	Short (EC-450BI5, 152 cm); Long (EN-450T5, 200 cm)	(90-120)	Abnormal liver enzyme levels associated with abdominal pain and/or dilated bile ducts on non-invasive imaging (n = 62), Dilated bile ducts on imaging (n = 21), Cholangitis (n = 20), Abnormal liver enzyme levels (n = 11), Pancreatitis (n = 8), Other (n = 7)	Needle-knife precut papillotomy, free-hand (n = 19), Needle-knife precut over a pancreatic stent (n = 2), Needle-knife sphincterotomy over a biliary stent (n = 8), Pull-type sphincterotomy, biliary (n = 12), Pull-type sphincterotomy, pancreatic (n = 3), Anastomotic stricturoplasty in non-transplant hepaticojejunostomy (n = 10), Anastomotic stricturoplasty in transplant hepaticojejunostomy (n = 6), Papillary balloon dilation (n = 12), Stone extraction (1 pancreatic), (n = 21), Non-anastomotic stricture dilation (n = 16), Direct cholangioscopy (n = 11), Biliary stenting (n = 19), Pancreatic stenting (n = 6), Biliary stricture tissue sampling (n = 6)
Varabei et al[47]	Long (EN-450P, 200 cm)	85 (45-120)	Jaundice (n = NR), Cholestasis (n = NR), Cholangiolithiasis (n = NR), Recurrent cholangitis (n = NR), Strictures of HJA (n = NR)	Reconstructive re-operations on the biliary tract (n = 6), Laser vaporizations (n = 3), Stone extraction (n = 2), Lithotripsy (n = 1), Stone extraction and laser vaporization (n = 1)
Cheng et al[26]	Short (EC-450BI5, 152 cm) and Long (EN-450T5, 200 cm)	80 (60-120)	Cholangitis (n = 43), Choledocholithiasis (n = 9), Malignancy (n = 11), Pancreatitis (n = 6), Abnormal liver enzymes Dilated bile duct on imaging (n = 2)	Bile duct stone extraction (n = 49), Cystic duct stone extraction (n = 1), Malignant biliary stricture (n = 6), dilation (n = 9), Biliary dilation alone (n = 9)
Sakakihara et al[48]	Short (EC-450BI5, 152 cm)	-	Stenosis of choledochojejunal anastomosis	Balloon dilation and/or endoscopic biliary stenting
Tsou et al[58]	Short (EC-450BI5, 152 cm); Long (EN-450T5, 200 cm)	45.8 (10-141)	Choledocholithiasis (n = 35), Anastomotic stricture without stones (n = 6), Malignant obstruction (n = 6)	Endoscopic sphincterotomy (n = 4), Balloon dilation (n = 34), Stone extraction (n = 30), Stent placement (n = 10)
Tsutsumi et al[49]	Short (EC-450BI5 and EI-530B, 152 cm)	50 (9-167)		Balloon dilation (n = 47), Stone extraction (n = 17), Endoscopic biliary stenting (n = 18), Endoscopic nasobiliary drainage (n = 28), Peroral direct cholangioscopy (n = 9)
De Koning and Moreels[6]	Long (EN-450T5, 200 cm)	-	Cholangiogram	Biliary anastomosis balloon dilatation Sphincterotomy Precut sphincterotomy Sphincteroplasty Biliary stone removal Biliary plastic stent placement/removal Removal of surgical sutures at biliary anastomosis Treatment of biliary metallic stent ingrowth
Shimatani et al[50]	Short (EI-530B, 152 cm)	22.4 (± 20.8) to reach blind end56.3 (± 32.5) to complete ERC-related interventions	Cholangitis (n = 173), Hepatobiliary disorder without jaundice (n = 60), Obstructive jaundice (n = 43), Bile duct stones (n = 24), Hepatic abscess (n = 4), Others (n = 7)	-
Tomoda et al[59]	Short (EC-450BI5 and EI-530B, 152 cm)	75 (42-180)	Biliary atresia (n = 4), Liver cirrhosis (n = 10), Hepatocellular carcinoma (n = 3), Hepatitis B virus (n = 6), Hepatitis C virus (n = 4), Non-B and non-C hepatitis virus (n = 1), Primary sclerosing cholangitis (n = 1), Primary biliary cirrhosis (n = 2), Alagille syndrome (n = 1), Budd-Chiari syndrome (n = 1)	-
Liu et al[60]	Long (EN-450T5, 200 cm)	-	Biliary obstruction (n = 63), Cholestatic liver function tests (n = 41), Abnormal biliary imaging (n = 31), Ascending cholangitis (n = 14), Stent removal or replacement (n = 17), Bile leak (n = 3), Recurrent pancreatitis (n = 1), Biliary hemorrhage (n = 1), Other (n = 1)	Stent placement (n = 25), Stent removal (n = 11), Dilatation (n = 11), Biopsy/brushing (n = 1)
Shimatani et al[7]	Short (EI-580BT, 155 cm; EI-530B, 152 cm)	54 (37-73)	Bile duct stones (n = 28), Benign stenosis of hepatocyclic acid and hematologic angiogenesis (n = 24), Cholangitis (n = 21), Intrahepatic stones (n = 19), Obstructive jaundice (n = 12), Malignant stenosis of hepatocyclic acid and hematologic angiogenesis (n = 6), Others (n = 2)	Sphincterotomy, Dilation of hepatocyclic acid and hematologic angiogenesis, Stone extraction, Stent placement
Tsutsumi et al[61]	Short (EI-580BT, 155 cm; EI-530B, 152 cm); Long (EN-450T5, 200 cm)	89 (70-103)	Cholangitis (n = 20), Elevated hepatobiliary enzyme (n = 8), Liver abscess (n = 3), Hepatolithiasis (n = 2), Localized intrahepatic bile duct dilation (n = 1)	Stent placement (n = NR), Stone extraction (n = NR)
Kashani et al[31]	Long (450T5, 200 cm)	109 (93-109)	Sphincter of Oddi dysfunction (n = 66), Choledocholithiasis (n = 26), Pancreatitis (n = 9), Biliary stricture/obstruction (n = 8), Bile leak (n = 8), Cholangitis (n = 6), Abnormal liver tests (n = 5), Recurrent liver abscess (n = 1)	-
Matsumoto et al[51]	Short (EI-580BT, 155 cm; EI-530B, 152 cm)	62 (40-74)	Bile leakage (n = 11)	Treatment for bile leakage (drainage) (n = 11)
Mizukawa et al[62]	Short (EI-530B and EC-450BI5, 152 cm)	54 (37-82)	Benign hepatocyclic acid and hematologic angiogenesis structure (n = 52)	Biliary stone extraction (n = 12), Nasobiliary drainage (n = 38)
Yamada et al[63]	Short (EI-580BT, 155 cm; EI-530B, 152 cm)	55 (37-87), EI-580BT; 62 (41-88), EI-530B	Biliary strictures (n = 72), Anastomosis stenoses (n = 113), Choledocholithiasis (n = 94), Intrahepatic stone (n = 55), Miscellaneous (n = 11)	Biliary stone extraction (n = 148), Biliary plastic stenting (n = 101), Biliary metallic stenting (n = 20), Balloon dilation of biliary anastomotic stricture (n = 106), Endoscopic papillary balloon dilation (n = 59), Endoscopic papillary large balloon dilation (n = 24), Endoscopic nasobiliary drainage (n = 151), Pancreatic stone extraction (n = 9), Pancreatic plastic stenting (n = 18), Balloon dilation of pancreatic anastomotic stricture (n = 14), Endoscopic nasopancreatic drainage (n = 16)
Nishio et al[52]	Short (EI-580BT, 155 cm; EI-530B, 152 cm)	43.5 (28.3-61.5) in LO group vs 30 (21-44) in control group	Stenosis of hepaticojejunostomy, bile duct stones, cholangitis, stenosis of biliary duct and others	Balloon dilation, stone extraction, stent placement
Sato et al[53]	Short (EI-580BT, 155 cm; EI-530B and EC-450BI5, 152 cm)	70 (15-240)	Hepaticojejunostomy anastomotic stricture	Balloon dilation and Balloon dilation + plastic stent placement
Sirin and Hulagu[54]	Long (EN-450T5, 200 cm)	-	Biliary stone (n = 15), Stenosis (n = 3), Cholestasis (n = 1), painless jaundice (n = 3), Pancreatic head tumor (n = 3), biliary duct dilatation (n = 3), Cholangiocarcinoma (n = 3)	Extraction of biliary stone by balloon, dilation of stenosis, sphincterotomy and extraction of biliary stone by balloon, biliary stenting, sphincterotomy
Uchida et al[32]	Short (EI-580BT, 155 cm; EI-530B and EC-450BI5, 152 cm)	Median 60	Choledochojejunal anastomosis stenosis (443 procedures), bile duct stones (126 procedures), biliary stricture (177 procedures), pancreatic indications (56 procedures), others (3 procedures)	Plastic stent placement for stenosis, complete stone removal for bile duct stones, diagnostic ERCP
Zamora Nava et al[64]	Long (EN-450T5 and EN-580T, 200 cm); Short (EC-450BI5, 152 cm)	-	Mainly cholangitis (49%), other indications include cholestatic pattern in liver function tests, documented stenosis of hepaticojejunostomy, or lithiasis by imaging studies (CT or MRCP)	Dilation (94.6%), stone extraction (78.6%), sphincterotomy/precut (10.7%), stent placement (7.1%), lithotripsy (1.8%)
CHENG et al[55]	Short (EI-580BT, 155 cm)	115.8 (40-275)	Bile duct stone (40.5%), painless obstructive jaundice (40.5%), acute cholangitis (13.5%), acute pancreatitis (5.5%)	Stone extraction or mechanical lithotripsy (n = 23), Sphincterotomy/sphincteroplasty (n = 18), Stricture dilatation (n = 7), Plastic stent insertion (n = 11), Metallic stent insertion (n = 6), Biopsy/brush cytology (n = 4)
Obata et al[56]	Short (EI-580BT, 155 cm; EI-530B, 152 cm)	90 (67-120)	CBD stones	Precut alone 4 (n = 6), EST alone 6 (n = 10), EPBD alone 9 (n = 14), EPLBD alone 5 (n = 8), Precut + EPBD 12 (n = 19), Precut + EPLBD 5 (n = 8), EST + EPBD 12 (n = 19), EST + EPLBD 5 (n = 8), None 5 (n = 8)
Sato et al[57]	Short (EI-580BT, 155 cm)	63 (35-86)	Treatment of hepaticojejunostomy anastomotic strictures	Placement of fully-covered metal stent (FCSEMS) for HJASs; balloon dilation of stricture prior to stent placement; additional plastic stent placement in some cases as “rescue stent”
Farina et al[65]	Short (EI-580BT, 155 cm); Long (EN580T, 200 cm)	-	Cholangitis or jaundice caused by benign/malignant biliary stenosis of the common bile duct or stenosis of a biliodigestive anastomosis, common bile duct gallstones, biliary leak, and removal of previously placed stents	Sphincterotomy, stone extraction, or pancreaticobiliary stent placement
Yokoyama et al[66]	Short (EI-580BT, 155 cm; EI-530B and EC-450BI5, 152 cm); Long (EN-450P5 and EN-450T5, 200 cm)	96 ± 43	Biliary stone	Stone extraction (n = 257)

CBD: Common bile duct; ERCP: Endoscopic retrograde cholangiopancreatography; LFT: Liver function tests; CT: Computed tomography; ERC: Endoscopic retrograde cholangiography; EST: Endoscopic sphincterotomy; EPBD: Endoscopic papillary balloon dilation; EPLBD: Endoscopic papillary large balloon dilation.