ERCP in Surgically Altered Anatomy Patients

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is a challenging clinical situation. In order to successfully perform such procedures, the clinician must first understand the indications for ERCP, the surgical anatomy involved which can often be complex, the equipment needed including endoscopes and accessories, and finally the different alternative approaches if failure occurs. In addition, with the advent of bariatric bypass surgery, altered anatomy ERCP has not only grown in complexity but also in volume given that both rapid weight loss and bariatric surgery are associated with increased biliary lithogenicity and its complications. The development of novel endoscopes and assist devices such as the single-balloon enteroscope (SBE), double-balloon enteroscope (DBE), and spiral enteroscope (SE) as well as accessories such as the transparent cap has facilitated and increased the capabilities of the endoscopic approach in the management of biliary pathologies in altered anatomy. However, the expanding technology can also be often confusing to the clinician, and proper selection of the appropriate endoscope, assist devices, and accessories requires a deep understanding of both the patient’s anatomy and subtle nuances in the different endoscopic tools. Despite these challenges, the current success rate of altered anatomy ERCP is quite respectable ranging from 60% to 91% depending on the anatomy involved. In addition, in the event of failure with the traditional endoscopic route, several novel techniques have been developed including the laparoscopic-assisted ERCP (LA-ERCP), the ERCP via the gastrostomy tract (GT), the percutaneous-assisted transprosthetic endoscopic therapy (PATENT), and the interventional radiology (IR) or endoscopic ultrasound (EUS)-assisted ERCP.