Endoscopic retrograde cholangiopancreatography in surgically altered anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in a surgically altered anatomy is a technically challenging undertaking with variable success and adverse event rates. There are several potential challenges to successfully perform an ERCP in patients with surgically altered anatomy such as identification of afferent limb, accessing and visualization of the papilla, and selective cannulation of the biliary and pancreatic ducts from altered orientation of the papilla. Several strategies to improve the success rate have been recommended by various endoscopy experts. In this review, we discussed the published literature involving various ERCP techniques described for surgically altered anatomies.