Endoscopic retrograde cholangiopancreatography in patients with altered anatomy: How to deal with the challenges?

Figure 3 View. A: Endoscopic view of the distal approach to cannulate an intact papilla of Vater using a straight catheter with a forward-viewing endoscope. In order to cannulate in the direction of the common bile duct, the papilla is rotated into the 7 o’clock position; B: Radiological view of the double-balloon enteroscope in a patient with Roux-en-Y gastric bypass. The distal approach with a forward-viewing endoscope allows straight cannulation of the common bile duct (white arrow) in line with the direction of the working channel.