Balloon-assisted ERCP for bile duct stones in surgically altered anatomy: current techniques, devices, and evolving strategies

Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has become an essential modality for managing pancreaticobiliary diseases in patients with surgically altered anatomy (SAA). This review summarizes the current evidence and technical advances in BE-ERCP, with a focus on insertion strategies tailored to specific reconstructive surgical techniques. Recent developments in short-type balloon endoscopes have improved maneuverability and device compatibility, enabling the widespread use of standard ERCP accessories. In addition, innovative tools, such as highly rotatable sphincterotomes, helical stone retrieval baskets, and newly introduced slim cholangioscopes, have expanded the diagnostic and therapeutic potential of BE-ERCP. Papillary interventions, including endoscopic sphincterotomy, endoscopic papillary balloon dilation (EPBD), large balloon dilation (EPLBD), and combined approaches (ESBD), are discussed with respect to their feasibility and safety in SAA. Furthermore, the clinical efficacy of stone removal and lithotripsy techniques, including peroral cholangioscopy-guided electrohydraulic lithotripsy, is reviewed. Finally, we address the emerging role of interventional endoscopic ultrasound as a complementary or alternative strategy to BE-ERCP. Taken together, this review provides a comprehensive update on current techniques and evolving strategies for endoscopic management of bile duct stones in patients with altered anatomy.