Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Anatomy

Abstract

This review describes the recent advances and evolving techniques in endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) and highlights the novel alternative approaches for pancreato-biliary interventions in this group of patients. The limitations of ERCP in patients with SAA have led to the development of improved endoscopic devices and accessories, and alternative approaches for pancreato-biliary interventions. Dedicated short-type single and double balloon enteroscopes (BE) have been developed with increased maneuverability and larger accessory channels that enhance scope insertion and allow the use of various ERCP devices, respectively. In failed BE-ERCP cases, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been used to gain access to the pancreato-biliary system, with high reported procedural success. More recently, lumen-apposing metal stent (LAMS) has been used to create a temporary bridge to the excluded stomach in Roux-en-Y gastric bypass (RYGB), and the small bowel loop in other altered GI anatomy, through which conventional ERCP can be performed, with excellent preliminary results. Several novel approaches and techniques are developed and being evaluated for pancreato-biliary intervention in patients with SAA. The optimal approach should be considered based on patient history, institutional factors, and multidisciplinary collaboration.