title: A multicenter experience of through-the-scope balloon-assisted enteroscopy in surgically altered gastrointestinal anatomy.
abstract: Surgically altered gastrointestinal anatomy poses challenges for deep enteroscopy. Current overtube-assisted methods have long procedure times and utilize endoscopes with smaller working channels that preclude use of standard accessories. A through-the-scope balloon-assisted enteroscopy (TTS-BAE) device uses standard endoscopes with a large working channel to allow metallic and plastic stent insertion. We aim to determine the efficacy and safety of TTS-BAE in patients with altered surgical anatomy.
  
  
  
  A retrospective, multicenter study of TTS-BAE in altered anatomy patients at two USA and one German institution was performed between January 2013 and December 2014. Type of anatomy, procedure indication and duration, adverse events, and target, technical, and clinical success were recorded.
  
  
  
  A total of 32 patients (mean age 54 years, Caucasian 81.6%, female 42.1%, mean BMI 25.4 kg/m2) underwent 38 TTS-BAE procedures. Thirty-two percent of cases had a prior attempt at conventional enteroscopy which failed to reach the target site. The target was successfully reached in 23 (60.5%) cases. Of the 23 cases that reached the intended target, 22 (95.7%) achieved technical success and 21 (91.3%) achieved clinical success. The median procedure time was 43 min. Target, technical, and clinical success rates for TTS-BAE-assisted ERCP (n = 31) were 58.1, 54.8 and 54.8%. Seven self-expandable metallic stents (five biliary, two jejunal) were attempted, and all successfully deployed. Adverse events occurred in 4 (10.4%) cases, including one luminal perforation.
  
  
  
  TTS-BAE is an alternative to overtube-assisted enteroscopy that is comparable in safety in patients with surgically altered anatomies. Technical success in the instances where the target had been reached was excellent. TTS-BAE confers an advantage over overtube-assisted enteroscopy as it can facilitate the deployment of self-expandable metallic stents in the biliary tree and deep small bowel.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA.
authors.forename: Jennifer X
authors.initials: JX
authors.lastname: Cai
authors.affiliation: Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Diehl
authors.affiliation: Department of Internal Medicine II, HSK Hospital, Wiesbaden, Germany.
authors.forename: Ralf
authors.initials: R
authors.lastname: Kiesslich
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Storm
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA.
authors.forename: Mohamad H
authors.initials: MH
authors.lastname: El Zein
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA.
authors.forename: Alan H
authors.initials: AH
authors.lastname: Tieu
authors.affiliation: Department of Internal Medicine II, HSK Hospital, Wiesbaden, Germany.
authors.forename: Arthur
authors.initials: A
authors.lastname: Hoffman
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA.
authors.forename: Vikesh K
authors.initials: VK
authors.lastname: Singh
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA.
authors.forename: Mouen A
authors.initials: MA
authors.lastname: Khashab
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA. pokolo2@jhmi.edu.
authors.forename: Patrick I
authors.initials: PI
authors.lastname: Okolo
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower 7E, Suite 7125G, Baltimore, MD, 21287, USA. vkumbhari@gmail.com.
authors.forename: Vivek
authors.initials: V
authors.lastname: Kumbhari
mesh_terms: D000328:Adult; D000368:Aged; D000071087:Balloon Enteroscopy / Q000295:instrumentation / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods; D019723:Endoscopes; D005260:Female; D006801:Humans; D007421:Intestine, Small / Q000000981:diagnostic imaging* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging* / Q000628:therapy; D012189:Retrospective Studies; D000069322:Self Expandable Metallic Stents
keywords: Altered surgical anatomy; ERCP; Enteroscopy; Roux-en-Y gastric bypass