Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2019; 25(26): 3313-3333
Published online Jul 14, 2019. doi: 10.3748/wjg.v25.i26.3313
Current status of endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy
Chonlada Krutsri, Mitsuhiro Kida, Hiroshi Yamauchi, Tomohisa Iwai, Hiroshi Imaizumi, Wasaburo Koizumi
Chonlada Krutsri, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
Mitsuhiro Kida, Hiroshi Yamauchi, Tomohisa Iwai, Hiroshi Imaizumi, Wasaburo Koizumi, Department of Gastroenterology, Graduate School of Medicine, Kitasato University Hospital, Kanagawa 252-0375, Japan
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Mitsuhiro Kida, MD, PhD, Professor, Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Kanagawa 252-0375, Japan.
Telephone: +81-42-7788111 Fax: +81-42-7788390
Received: March 23, 2019
Peer-review started: March 25, 2019
First decision: April 11, 2019
Revised: April 18, 2019
Accepted: April 29, 2019
Article in press: May 18, 2019
Published online: July 14, 2019

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Keywords: : Endoscopic retrograde cholangiopancreatography, Surgically altered anatomy, Endoscopic retrograde cholangiopancreatography in Billroth II, Endoscopic retrograde cholangiopancreatography post-Whipple, Endoscopic ultrasonography-guided endoscopic retrograde cholangiopancreatography

Core tip: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is really challenging and requires a well-experienced endoscopist. Understanding the type of surgery, length of the afferent limb, type of endoscope used with choice of proper approach (peroral or transgastric), and compatible ERCP accessories with various endoscopic types are the keys to success. A conventional endoscope and device-assisted enteroscope-assisted ERCP are recommend for short-limb reconstruction with/without a native papilla, while device-assisted enteroscope-assisted ERCP, ERCP assisted by endoscopic ultrasonography, and especially laparoscopic-ERCP are highly recommended for long-limb reconstruction, such as Roux-en-Y gastric bypass with concomitant cholecystectomy.