Balloon Enteroscopy-assisted Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Situs Inversus Totalis With Billroth II Reconstruction: A Case Report and Literature Review.

Key Takeaways for GI Nurses

• Situs inversus totalis combined with Billroth II anatomy creates a "double reversal" that can complicate scope orientation, room setup, and equipment selection — anticipating these challenges during pre-procedure planning improves team readiness and procedural flow.
• In this case, standard prone positioning and conventional endoscopist positioning (right side of patient) were maintained, demonstrating that not every anatomical variant requires a complete overhaul of room setup — nurses should confirm positioning plans with the endoscopist rather than assuming modifications are always necessary.
• A short-type single-balloon enteroscope was successfully used to navigate the afferent limb to the papilla; nurses should be familiar with balloon-assisted enteroscopy equipment, including balloon inflation/deflation systems, overtubes, and troubleshooting for altered surgical anatomy cases.
• Successful biliary cannulation was achieved with a standard ERCP catheter (no sphincterotome needed), highlighting the importance of having a full range of accessories readily available, as the technical approach may deviate from the "expected" complex-case toolkit.

Clinical Relevance

Patients with situs inversus totalis and prior Billroth II gastrectomy represent a rare but instructive subset of ERCP cases that test the adaptability of the entire endoscopy team. For nursing staff, this case underscores the value of thorough chart review and imaging assessment prior to the procedure. Recognizing surgical history and congenital anatomical variants in advance allows the team to anticipate equipment needs — such as balloon enteroscopes and overtubes — and to communicate proactively with the endoscopist about anticipated technical approaches, reducing delays and improving safety during the case.

This report also reinforces that altered anatomy does not automatically mandate altered patient positioning or endoscopist stance. The authors note that conventional prone positioning and standard right-side endoscopist placement were maintained, with success attributed to favorable alignment between the working-channel orientation and the mirrored papillary anatomy. For nurses, this is a reminder to remain flexible and follow the endoscopist's real-time clinical judgment rather than defaulting to assumptions based on anatomy alone. Clear communication during setup, and readiness to pivot equipment or positioning if the initial approach is unsuccessful, remain essential nursing competencies in these complex cases.

From a broader operational standpoint, cases like this highlight the importance of maintaining an inventory of balloon-assisted enteroscopy equipment and biliary accessories (standard ERCP catheters, sphincterotomes, dilation balloons, basket catheters) even in units that do not perform altered-anatomy ERCP frequently. Additionally, this case reinforces the nursing role in post-procedure monitoring for complications such as post-ERCP pancreatitis, which did not occur here but remains a key risk requiring vigilant assessment regardless of anatomical complexity. Exposure to case reports like this also supports professional development, helping nurses build pattern recognition for rare anatomical combinations they may encounter only once or twice in a career.

Bottom Line

This case demonstrates that ERCP in patients with situs inversus totalis and Billroth II anatomy can be performed safely using standard positioning and equipment when approached thoughtfully, reinforcing the importance of pre-procedure anatomical review, readiness with balloon-assisted enteroscopy tools, and close collaboration with the endoscopist to adapt technique in real time rather than relying on rigid protocols for anatomically complex cases.