Approach to biliary access in patients with altered anatomy

Alteration in the upper digestive tract or pancreaticobiliary anatomy poses a challenge for successful endoscopic retrograde cholangiopancreatography (ERCP). The alterations can arise either after surgery or because of tumor or diverticulum. In this scenario, the papilla may be unreachable or difficult to cannulate. The situation is further compounded by the lack of dedicated instruments for such procedures. Endoscopic ultrasound-guided biliary intervention and device-assisted enteroscopy are 2 techniques that have been found to be useful for ERCP in patients with altered anatomy. The ability of endoscopic ultrasound to visualize the biliary tree and enteroscope to reach deep into the small intestine has proven to be useful for ERCP in patients with altered anatomy. The technical and functional success rates of both approaches are relatively high. However, they have been associated with complications that are higher than that associated with standard ERCP. This finding is likely related to the learning curve of these advanced therapeutic interventions. With improvement in devices, technique, and accessories, both procedures are emerging as viable alternatives to standard ERCP in patients with altered anatomy.