《Table 6 Success rates of double balloon enteroscope, single balloon enteroscope, and spiral enteros

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《Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy》

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DBE:Double balloon enteroscope；SBE:Single balloon enteroscope；SE:Spiral enteroscope；RYGB:Roux-en-Y gastric bypass.

Papillary intervention is important and performed prior to stone extraction or other therapeutic procedures.A common technique is endoscopic sphincterotomy（EST），but in cases of surgically altered anatomy，it is difficult to keep the EST knife in the proper direction and control limit size of cutting because of the reverse position of the papilla，difficult scope maneuverability，and improper accessories.Many techniques can facilitate easier EST，such as use of an S-shaped sphincterotome，rotatable sphincterotome，push-type sphincterotome，and needle-knife sphincterotomy（either free-hand or over a biliary stent）.The DBE working channel is located at the 6 to 7o’clock position，and the papilla needs to be brought to the 6 o’clock position for safe fixation.Conversely，the SBE working channel is located at 8 to 9 o’clock，making it more difficult to fix the papilla；additionally，the cutting should be directed toward 5-o’clock.If EST is too high-risk，endoscopic papillary balloon dilatation is the first option because of its low risk of bleeding and perforation.This technique is suitable for small and multiple CBD stones because of the small balloon diameter（6-8 mm）[41].For large and multiple CBD stones，endoscopic papillary large balloon dilatation（EPLBD）（diameter，12-18 mm） has a satisfactory success rate even when not combined with EST，and there is no significant difference in post-ERCP pancreatitis.The main reason for performing EPLBD is to avoid additional therapeutic procedures for stone extraction.The stone clearance rate by EPLBD alone is high（Table 7）；thus，EPLBD alone and EST plus EPLBD both have a higher therapeutic success rate than EST alone.Teoh et al[42]reported equal efficacy for removal of bile duct stones between EST alone and EST followed by EPLBD，which decreased the bleeding and perforation rates in the EPLBD group.In their systematic review，Kim et al[43]found that the overall success rate was 96.5%in EST with EPLBD and 97.2%in EPLBD alone with no significant difference.EPLBD alone is effective and safe for stone removal after Billroth II reconstruction with a first-session success rate of 92.5%[44].EPLBD can be used alone for papillary intervention to decrease EST-related complications such as bleeding and perforation，but caution is still needed because of possible post-ERCP pancreatitis.