ERCP in altered anatomy

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP), in the new millennium, is primarily therapeutic. Accurate diagnosis is usually obtained by computer-assisted tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasonography (EUS). ERCP is performed whenever endotherapy is required. At the same time, surgical interventions for malignant disease and weight-loss procedures are on the rise. Both procedures critically alter upper gastrointestinal tract anatomy, while many of them are associated with increased risk of biliopancreatic diseases requiring endotherapy. ERCP in altered anatomy is significantly more difficult than in normal anatomy. The success rate is lower and the complications higher when compared with ERCP in native anatomy. Each step of the procedure is a difficult obstacle to overcome. The first obstacle is to reach the papilla or the ductal anastomosis. The distance is usually quite longer compared to normal anatomy, while postoperative adhesions may create fixed loops and angulations that hamper endoscope advancement. The endoscopist may use a variety of endoscopes or employ dedicated devices to reach the required duct. The second obstacle is to perform cannulation, sphincterotomy, and all planned interventions. Cannulation as well as sphincterotomy, in the presence of a native papilla, is substantially more challenging especially when the position in front of the papilla is not very stable. In almost all cases, the papilla is reached from the caudal side, and all endotherapy is done in a “reverse” position. This adds to the difficulty of the intervention. Long enteroscopes, which are frequently used, require dedicated, longer, catheters to exit the working channel, but these catheters are not always readily available in all departments. These are some of the difficulties encountered while performing ERCP in a patient with surgically altered upper gastrointestinal anatomy. This chapter will mainly focus on endoluminal approaches to reach the papilla and perform biliopancreatic interventions. A small portion will be dedicated to EUS-guided and laparoscopy-assisted alternatives to perform endotherapy in patients with altered anatomy.