ERCP in Surgically Altered Anatomy

Abstract

There are several reasons that make altered anatomy endoscopic retrograde cholangiopancreatography (ERCP) difficult. These include lack of adequate endoscopic accessories, use of forward-viewing enteroscopes, alteration of angles with a caudal approach to the papilla, lack of an elevator, and difficulty in identification of biliopancreatic limb and papilla. Successful ERCP in patients with altered surgical anatomy requires a thorough understanding of the various surgical alterations in anatomy. A thorough history and review of records, including surgical operative reports and abdominal cross-sectional images, are highly recommended. A clear understanding of the types of endoscopes, their lengths, caliber of the working channel, and available accessories is needed when choosing the type of enteroscope. Both fluoroscopic and endoscopic visual cues should guide the endoscopist to correctly identifying the afferent limb and the papilla or the bilioenteric anastomosis. Understanding the anatomy of the papilla when approaching caudally, attaining stable scope position, and using endoscopic and fluoroscopic images to align the angle of the scope to the bile duct are important principles that help achieve successful therapeutic ERCP in patients with altered surgical anatomy.