Pancreaticobiliary Options in Patients with Altered Surgical Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed for accessing, imaging, and treating disorders of the biliary tree and pancreas but can be complicated in patients who have altered surgical anatomy from prior foregut surgery. Roux-en-Y and Billroth II reconstructions present a challenge to the endoscopist due to their consequent long afferent limbs and the retrograde approach to the ampulla. Alternative endoscopic access to the biliary tree is often warranted in these patients, including deep enteroscopy with the assistance of various overtubes, transgastric approaches utilizing the assistance of laparoscopy or internal endoscopic ultrasound, or direct biliary access under endoscopic ultrasound guidance. In this chapter, each of these access procedures will be reviewed along with their respective clinical applications and outcomes. Selection of the most appropriate management approach can be challenging and dependent on patient acuity, available resources, and technical expertise.