Tips and tricks of double-balloon endoscopic retrograde cholangiopancreatography (with video)

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically difficult in patients with altered gastrointestinal tract, double-balloon endoscopy (DBE) allows endoscopic access to pancreato-biliary system in such patients. Balloon dilation of biliary stricture and extraction of bile duct stones, placement of biliary stent in patients with Roux-en-Y or Billroth-II reconstruction, using DBE have been reported. However, two major technical parts are required for double-balloon ERCP (DB-ERCP). One is insertion of DBE and the other is an ERCP-related procedure. The important point of DBE insertion is a sure approach to the afferent limb with Roux-en-Y reconstruction or Braun anastomosis. Short type DBE with working length 152 cm is beneficial for DB-ERCP because it is short enough for most biliary accessory devices. In this paper, we introduce our tips and tricks for successful DB-ERCP.