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World J Gastrointest Endosc. Aug 16, 2014; 6(8): 345-351
Published online Aug 16, 2014. doi: 10.4253/wjge.v6.i8.345
Endoscopic retrograde cholangiopancreatography in patients with altered anatomy: How to deal with the challenges?
Tom G Moreels
Tom G Moreels, Department of Gastroenterology and Hepatology, Cliniques Universitaires St-Luc, B-1200 Brussels, Belgium
Author contributions: Moreels TG performed the endoscopic retrograde cholangiopancreatography procedures, did the literature review and wrote the manuscript.
Correspondence to: Tom G Moreels, MD, PhD, Department of Gastroenterology and Hepatology, Cliniques Universitaires St-Luc, Hippokrateslaan 10, B-1200 Brussels, Belgium. tom.moreels@uclouvain.be
Telephone: +32-2-7642892 Fax: +32-2-7648927
Received: December 10, 2013
Revised: June 3, 2014
Accepted: June 27, 2014
Published online: August 16, 2014
Processing time: 247 Days and 10.6 Hours
Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is challenging. Several operative interventions of both the gastrointestinal tract and the biliary and/or pancreatic system lead to altered anatomy, rendering ERCP more difficult or even impossible with a conventional side-viewing duodenoscope. Adapted endoscopes are available to reach the biliopancreatic system and to perform ERCP in patients with altered anatomy. However, both technical difficulties and complications determine the procedure’s success. Different technical approaches have been described and are highly dependent on local expertise and endoscopic equipment. Standardized practical guidelines are currently unavailable. This review focuses on the challenges encountered during ERCP in patients with altered anatomy and how to deal with them. The first challenge is reaching the papilla or the bilioenteric/pancreatoenteric anastomosis in the patient with postoperative altered anatomy. The second challenge is the cannulation of the biliopancreatic system and performing all conventional ERCP interventions and the third challenge is the control of possible complications. The available literature data on this topic is reviewed and illustrated with clinical cases.

Keywords: Endoscopic retrograde cholangiopancreatography; Altered anatomy; Billroth; Roux-en-Y

Core tip: Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy is difficult and faces several challenges. There are three important challenging steps in this endoscopic procedure: reaching the papilla or the bilioenteric/pancreatoenteric anastomosis, cannulation of the biliopancreatic system and prevention of endoscopic complications. Since there are no standardized practical and technical guidelines on this topic, this review illustrates these challenges with clinical cases.