Long Double-Balloon Enteroscopy for Biliary Access in Surgically Altered Anatomy: Outcomes and Technical Adaptations in Resource-Limited Settings

Background and Aims: Biliary obstruction in patients with surgically altered anatomy (SAA) poses significant challenges, particularly in resource-limited settings lacking short enteroscopes. This study evaluated the efficacy and safety of long double-balloon enteroscopy (DBE) with long guiding catheters and controlled radial expansion (CRE) balloons for biliary access. Methods: Between January 2021 and December 2023, 26 consecutive SAA patients with biliary obstruction underwent therapeutic long DBE at three tertiary centers in Egypt. The primary outcomes were technical success (defined as anastomosis reach and successful cannulation) and clinical success (defined as bilirubin normalization at 4 weeks). Secondary outcomes included procedure characteristics, complications, and the need for alternative interventions. Results: Technical success was achieved in 84.6% (22/26). Mean procedure time was 89 ± 32 minutes, with Roux-en-Y hepaticojejunostomy cases requiring longer times than choledochojejunostomy (102 ± 28 vs. 78 ± 24 min, p = 0.03). Bilirubin decreased significantly from 5.4 ± 3.1 to 1.2 ± 0.7 mg/dL at 4 weeks (p < 0.001). Complications occurred in 11.5% (3/26): two mild cholangitis and one self-limited bleeding. Four failures required alternative interventions (EUS-guided hepaticogastrostomy, percutaneous drainage, or Randex Voux technique). Conclusion: Long DBE with long guiding catheters enables effective biliary access in SAA patients, achieving outcomes comparable to high-resource settings. This strategy represents a practical solution for centers lacking short enteroscopes.