Motorized spiral enteroscopy in altered anatomy: Balancing clinical success with safety challenges

Abstract

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y-anatomy is technically challenging and additional techniques including balloon-assisted enteroscopy, endoscopic ultrasound (EUS) guided, and percutaneous approaches offers only modest success rates. Motorized spiral enteroscopy (MSE)-assisted ERCP (MSE-ERCP) has emerged as a potential alternative. In a retrospective study by Nennstiel et al, MSE-ERCP achieved high success rates for biliary entry (88%) and therapeutic intervention (83%). However, outcomes varied significantly between bilioenteric anastomosis (93%) and native papilla (63%), underscoring the importance of anatomy-driven procedural selection. Despite encouraging efficacy, the global withdrawal of the MSE platform due to serious device-related complications highlights the ongoing balance between feasibility and safety. Future directions should prioritize refinements in device engineering, multicenter prospective trials comparing MSE with balloon-assisted and EUS-guided techniques, and systematic outcome stratification by anatomical subgroup. Such efforts will be critical to defining the role of MSE within the therapeutic algorithm for surgically altered anatomy.

Keywords: Gastric bypass; Ampulla of Vater; Roux-en-Y anastomosis; Balloon enteroscopy; Cholangiopancreatography

Core Tip: Endoscopic retrograde cholangiopancreatography in Roux-en-Y anatomy remains technically challenging, with higher success through bilioenteric anastomosis than the native papilla. Emerging strategies including balloon-assisted enteroscopy, motorized spiral enteroscopy (MSE) and endoscopic ultrasound-guided drainage highlight the need for personalized procedural selection based on anatomy, clinical scenario, and institutional expertise. MSE offers high diagnostic and therapeutic potential but requires further refinement to address safety concerns before wider adoption.