Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Anatomy


Purpose of review

This review describes the recent advances and evolving techniques in endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) and highlights the novel alternative approaches for pancreato-biliary interventions in this group of patients.

Recent findings

The limitations of ERCP in patients with SAA have led to the development of improved endoscopic devices and accessories, and alternative approaches for pancreato-biliary interventions. Dedicated short-type single and double balloon enteroscopes (BE) have been developed with increased maneuverability and larger accessory channels that enhance scope insertion and allow the use of various ERCP devices, respectively. In failed BE-ERCP cases, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been used to gain access to the pancreato-biliary system, with high reported procedural success. More recently, lumen-apposing metal stent (LAMS) has been used to create a temporary bridge to the excluded stomach in Roux-en-Y gastric bypass (RYGB), and the small bowel loop in other altered GI anatomy, through which conventional ERCP can be performed, with excellent preliminary results.


Several novel approaches and techniques are developed and being evaluated for pancreato-biliary intervention in patients with SAA. The optimal approach should be considered based on patient history, institutional factors, and multidisciplinary collaboration.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Moreels T. Endoscopic retrograde cholangiopancreatography in patients with altered anatomy: how to deal with the challenges? World J Gastrointest Endosc. 2014;6:345–51.

    PubMed  PubMed Central  Article  Google Scholar 

  2. 2.

    Skinner M, Popa D, Neumann H, Wilcox CM. ERCP with the overtube-assisted enteroscopy technique : a systematic review. Endoscopy. 2014:560–72.

  3. 3.

    Ishii K, Itoi T, Tonozuka R, Itokawa F. Balloon enteroscopy – assisted ERCP in patients with Roux-en-Y gastrectomy and intact papillae (with videos). Gastrointest Endosc. 2016;83:377–386.e6.

    PubMed  Article  Google Scholar 

  4. 4.

    Sharaiha RZ, Kumta NA, Desai AP, Defilippis EM, Gabr M, Sarkisian AM, et al. Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: predictors of successful outcome in patients who fail endoscopic retrograde cholangiopancreatography. Surg Endosc. 2016;30(12):5500–5.

    PubMed  Article  Google Scholar 

  5. 5.

    Schreiner MA, Chang L, Gluck M, Irani S, Gan I, Brandabur JJ, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc. 2012;75:748–56.

    PubMed  Article  Google Scholar 

  6. 6.

    Matsushita M, Shimatani M, Tanaka T, Fukata N, Kawamata S, Okazaki K. Short double-balloon enteroscope for previously failed colonoscopy. Gastrointest Endosc. 2011;73:854–5.

    PubMed  Article  Google Scholar 

  7. 7.

    Kawaguchi Y, Yamauchi H, Kida M, Okuwaki K, Iwai T, Uehara K, et al. Failure factors to reach the blind end using a short-type single- balloon enteroscope for ERCP with Roux-en-Y reconstruction : a multicenter retrospective study. Gastroenterol Res Pract. 2019.

  8. 8.

    Yamauchi H, Kida M, Okuwaki K, Miyazawa S. Therapeutic peroral direct cholangioscopy using a single balloon enteroscope in patients with Roux-en-Y anastomosis ( with videos ). Surg Endosc. 2018;32:498–506.

    PubMed  Article  Google Scholar 

  9. 9.

    Shimatani M, Tokuhara M, Kato K, Miyamoto S, Masuda M, Sakao M, et al. Utility of newly developed short-type double-balloon endoscopy for endoscopic retrograde cholangiography in postoperative patients. J Gastroenterol Hepatol. 2017;32:1348–54.

    PubMed  Article  Google Scholar 

  10. 10.

    • Mukai S, Itoi T, Sofuni A, Tsuchiya T, Tanaka R, Tonozuka R, et al. EUS-guided antegrade intervention for benign biliary diseases in patients with surgically altered anatomy (with videos). Gastrointest Endosc. 2019;89:399–407A retorospective study on the efficacy and the safety of EUS-guided antegrade intervention including cholangioscopy-guided antegrade intervention.

    PubMed  Article  Google Scholar 

  11. 11.

    Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K. EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc. 2015;82:560–5.

    PubMed  Article  Google Scholar 

  12. 12.

    •• Mutignani M, Forti E, Larghi A, Pugliese F, Cintolo M, Massad M, et al. Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy Authors. Endoscopy. 2019;51:1146–50 Largest published data on EDEE including 32 patients with non-RYGB which showed 100% technical success for both stent placement and ERCP with two adverse events that were managed conservatively. In 29 patients, PTBD was needed in order to opacify the small bowel with contrast for targeting with EUS.

    PubMed  Article  Google Scholar 

  13. 13.

    Beyna T, Schneider M, Pullmann D, Gerges C, Kandler J, Neuhaus H. Motorized spiral colonoscopy: a first single-center feasibility trial. Endoscopy. 2018;50:518–23.

    PubMed  Article  Google Scholar 

  14. 14.

    Yane K, Katanuma A, Maguchi H, Takahashi K, Kin T, Ikarashi S, et al. Short-type single-balloon enteroscope-assisted ERCP in postsurgical altered anatomy: potential factors affecting procedural failure. Endoscopy. 2017;49:69–74.

    PubMed  Google Scholar 

  15. 15.

    Moreels TG, Kouinche Madenko N, Taha A, Piessevaux H, Depreez PH. Therapeutic enteroscopy using a new single balloon enteroscope: a case series. Endosc Int Open. 2016;4:918–21.

    Article  Google Scholar 

  16. 16.

    Shimatani M, Takaoka M, Tokuhara M, Kato K, Miyoshi H, Ikeura T, et al. Through-thescope self-expanding metal stent placement using newly developed short double-balloon endoscope for the effective management of malignant afferent-loop obstruction. Endoscopy. 2016;48:E6–7.

    PubMed  Article  Google Scholar 

  17. 17.

    Mouradides C, Taha A, Moreels TG. What is the advantage of a passive bending segment in balloon enteroscopy-assisted ERCP? Endoscopy. 2017;49:405.

    PubMed  Article  Google Scholar 

  18. 18.

    • Yamada A, Kogure H, Nakai Y, Mizuno S, Tada M, Koike K, et al. Performance of a new short-type double-balloon endoscope with advanced force transmission and adaptive bending for pancreaticobiliary intervention in patients with surgically altered anatomy: a propensity-matched analysis. Dig Endosc. 2019;31:86–93 This study compared the new short DBE with high force transmission and adaptive bending with the previous short DBE and demonstrated significant decrease in procedure time with the use of the new DBE.

    PubMed  Article  Google Scholar 

  19. 19.

    Tanisaka Y, Ryozawa S, Mizuide M, Harada M, Fujita A, Ogawa T, et al. Analysis of the factors involved in procedural failure : surgically altered gastrointestinal anatomy. Dig Dis Sci. 2019;31:682–9.

    Google Scholar 

  20. 20.

    • Tanisaka Y, Ryozawa S, Mizuide M, Kobayashi M, Fujita A, Minami K, et al. Usefulness of the “ newly designed ” short-type single-balloon enteroscope for ERCP in patients with Roux-en-Y gastrectomy: a pilot study. Endosc Int Open. 2018;6:1417–22 This study compared the new short SBE with high force transmission and adaptive bending with the previous short SBE and demonstrated significantly higher procedural success and diagnostic success, and less procedural time.

    Article  Google Scholar 

  21. 21.

    Shimatani M, Hatanaka H, Kogure H, Tsutsumi K, Kawashima H, Hanada K, et al. Diagnostic and therapeutic endoscopic retrograde cholangiography using a short-type double-balloon endoscope in patients with altered gastrointestinal anatomy: a multicenter prospective study in Japan. Am J Gastroenterol. 2017;49:75–9.

    Google Scholar 

  22. 22.

    Mizukawa S, Tsutsumi K, Kato H, Muro S, Akimoto Y, Uchida D, et al. Endoscopic balloon dilatation for benign hepaticojejunostomy anastomotic stricture using short double-balloon enteroscopy in patients with a prior Whipple’ s procedure : a retrospective study. BMC Gastroentrol. 2018;18:1–9.

    Article  Google Scholar 

  23. 23.

    Wen-Guang W, Lu-Cui Q, Xiao-Ling S, Ming-Ning Z, Wen-Jie Z, Jun Gu H, et al. Application of single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients after bilioenteric Roux-en-Y anastomosis: experience of multi-disciplinary collaboration. World J Gastroenterol. 2019;25:5505–14.

    Article  Google Scholar 

  24. 24.

    Uchida D, Tsutsumi K, Kato H, Matsumi A, Saragai Y, Tomoda T. Potential factors affecting results of short-type double-balloon endoscope assisted endoscopic retrograde cholangiopancreatography. Dig Dis Sci. 2019.

  25. 25.

    Sato T, Kogure H, Nakai Y, Ishigaki K, Hakuta R, Saito K. Double balloon endoscopy assisted treatment of hepaticojejunostomy anastomotic strictures and predictive factors for treatment success. Surg Endosc. 2019.

  26. 26.

    Farrell TM, Haggerty SP, Overby DW, Kohn GP, Richardson WS, Fanelli RD. Clinical application of laparoscopic bariatric surgery: an evidence-based review. Surg Endosc. 2009;23:930–49.

    PubMed  Article  Google Scholar 

  27. 27.

    Dogan K, Homan J, Aarts EO, Van Laarhoven CJ, Janssen IM, Berends FJ. A short or a long Roux limb in gastric bypass surgery: does it matter? Surg Endosc. 2017;31:1882–90.

    PubMed  Article  Google Scholar 

  28. 28.

    Moreels T. Altered anatomy: enteroscopy and ERCP procedure. Best Pr Res Clin Gastroenterol. 2012;26:347–57.

    Article  Google Scholar 

  29. 29.

    Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN. Spiral enteroscopy – assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc. 2019;87:1241–7.

    Article  Google Scholar 

  30. 30.

    Cai JX, Diehl DL, Kiesslich R, Storm AC, El Zein MH, Alan Z, et al. A multicenter experience of through-the-scope balloon-assisted enteroscopy in surgically altered gastrointestinal anatomy. Surg Endosc. 2017;31(7):2753–62.

    PubMed  Article  Google Scholar 

  31. 31.

    Takenaka M, Yamao K, Kudo M. A novel method of biliary cannulation for patients with Roux-en-Y anastomosis using a unique, uneven, double lumen cannula (uneven method). Dig Endosc. 2018;30:808–9.

    PubMed  Article  Google Scholar 

  32. 32.

    Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 2016;48:657–83.

    PubMed  Article  Google Scholar 

  33. 33.

    Yasuda I, Fujita N, Maguch H, Hasebe O, Igarashi Y, Murakami H, et al. Long-term outcomes after endoscopic sphincterotomy versus endoscopic papillary balloon dilation for bile duct stones. Gastrointest Endosc. 2010;72:1185–91.

    PubMed  Article  Google Scholar 

  34. 34.

    Nakai Y, Kogure H, Yamada A, Isayama H, Koike K. Endoscopic management of bile duct stones in patients with surgically altered anatomy. Dig Endosc. 2018;30:67–74.

    PubMed  Article  Google Scholar 

  35. 35.

    Kim TH, Kim JH, Seo DW, Lee DK, Reddy ND, Rerknimitr R, et al. International consensus guidelines for endoscopic papillary large-balloon dilation. Gastrointest Endosc. 2016;83:37–47.

    PubMed  Article  Google Scholar 

  36. 36.

    Matsumoto K, Tsutsumi K, Kato H, Akimoto Y. Effectiveness of peroral direct cholangioscopy using an ultraslim endoscope for the treatment of hepatolithiasis in patients with hepaticojejunostomy (with video). Surg Endosc. 2016;30:1249–54.

    PubMed  Article  Google Scholar 

  37. 37.

    Dimou FM, Adhikari D, Mehta HB, Olino K, Riall TS, Brown KM. Incidence of hepaticojejunostomy stricture after hepaticojejunostomy. Surgery. 2016;160:691–8.

    PubMed  PubMed Central  Article  Google Scholar 

  38. 38.

    House MG, Cameron JL, Schulick RD, Campbell KA, Sauter PK, et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg. 2006;243:571–6.

    PubMed  PubMed Central  Article  Google Scholar 

  39. 39.

    Tomoda T, Tsutsumi K, Kato H, Mizukawa S, Yabe S, Akimoto Y, et al. Outcomes of management for biliary stricture after living donor liver transplantation with hepaticojejunostomy using short-type double-balloon enteroscopy. Surg Endosc. 2016;30:5338–44.

    PubMed  Article  Google Scholar 

  40. 40.

    Yamauchi H, Kida M, Miyata E, Okuwaki K, Iwai T, Minato N, et al. Endoscopic balloon dilation for benign bilioenteric stricture: outcomes and factors affecting recurrence. Dig Dis Sci. 2019;64:3557–67.

    PubMed  Article  Google Scholar 

  41. 41.

    • Tomoda T, Kato H, Miyamoto K, Saragai Y, Mizukawa S, Yabe S. Comparison between endoscopic biliary stenting combined with balloon dilation and balloon dilation alone for the treatment of benign hepaticojejunostomy anastomotic stricture. J Gastrointest Surg. 2019.This study compared the stricture recurrence in patients with benign anastomotic stricture treated with either balloon dilatation or plastic stent, and reported a significant higher 1- and 3-year patency rates in stent group.

  42. 42.

    Yamauchi H, Tadehara M, Kida M. Temporary non-flared fully covered self-expandable metal stent placement for refractory benign choledochojejunal anastomotic stricture. Dig Endosc. 2018;30:541–2.

    PubMed  Article  Google Scholar 

  43. 43.

    Shibuya H, Hara K, Mizuno N, Hijioka S, Imaoka H, Tajika M, et al. Treatment of biliary strictures with fully covered self-expandable metal stents after pancreaticoduodenectomy. Endoscopy. 2017;49:75–9.

    PubMed  Article  Google Scholar 

  44. 44.

    Yamauchi H, Kida M, Okuwaki K, Miyazawa S, Iwai T, Imaizumi H, et al. A case series: outcomes of endoscopic biliary self-expandable metal stent for malignant biliary obstruction with surgically altered anatomy. Dig Dis Sci. 2016;61:2436–41.

    PubMed  Article  Google Scholar 

  45. 45.

    Bowman E, Greenberg J, Garren M, Guda N, Rajca B, Benson M, et al. Laparoscopic-assisted ERCP and EUS in patients with prior Roux-en-Y gastric bypass surgery: a dual center case series experience. Surg Endosc. 2016;30:4647–52.

    PubMed  Article  Google Scholar 

  46. 46.

    • Da Ponte AM, Bernardo WM, Coutinho LM, Iatagan J, Brunaldi VO, De Moura DTH, et al. Comparison between enteroscopy-based and laparoscopy-assisted ERCP for accessing the biliary tree in patients with Roux-en-Y gastric bypass: systematic review and meta-analysis. Surg Endosc. 2018;28:4064–76.

    Google Scholar 

  47. 47.

    • Nakai Y, Isayama H, Koike K. Two-step endoscopic ultrasonography-guided antegrade treatment of a difficult bile duct stone in a surgically altered anatomy patient. Dig Endosc. 2018;30:125–7.

    PubMed  Article  Google Scholar 

  48. 48.

    Nakai Y, Sato T, Hakuta R, Ishigaki K, Saito K, Saito T, et al. Management of difficult bile duct stones by large balloon, cholangioscopy, enteroscopy and endosonography Gut Liver. 2019;1–9.

  49. 49.

    Shimatani M, Mitsuyama T, Takaoka M, Kazuichi O. Role of two-step endoscopic ultrasonography-guided antegrade treatment as an option for bile duct stones in patients with surgically altered anatomy. Dig Endosc. 2018;30:50–1.

    PubMed  Article  Google Scholar 

  50. 50.

    • Kashab MA, El Zein MHSK. EUS-guided biliary drainage or enteroscopy-assisted ERCP in patients with surgical anatomy and biliary obstruction: in international comparative study. Endosc Int Open. 2016;4:1322–E1327This study compared the outcomes of DAE-ERCP with EUS-BD in patients with SAA and reported that that EUS-BD has higher efficacy, but DAE-ERCP has a better safety profile.

    Article  Google Scholar 

  51. 51.

    Iwashita T, Nakai Y, Hara K, Isayama H, Park DH. Endoscopic ultrasound-guided antegrade treatment of bile duct stone in patients with surgically altered anatomy: a multicenter retrospective cohort study. J Hepatobiliary Pancreat Sci. 2016;23:227–33.

    PubMed  Article  Google Scholar 

  52. 52.

    Miranda-García P, Gonzalez JM, Tellechea JI, Culetto A, Barthet M. EUS hepaticogastrostomy for bilioenteric anastomotic strictures: a permanent access for repeated ambulatory dilations? Results from a pilot study. Endosc Int Open. 2016;4:461–5.

    Article  Google Scholar 

  53. 53.

    Iwashita T, Yasuda I, Mukai T, Iwata K, Doi S, Uemura S, et al. Endoscopic ultrasound-guided antegrade biliary stenting for unresectable malignant biliary obstruction in patients with surgically altered anatomy: single-center prospective pilot study. Dig Endosc. 2017;29:362–8.

    PubMed  Article  Google Scholar 

  54. 54.

    • Chen YI, Levy MJ, Moreels TG, Hajijeva G, Will U, Artifon EL, et al. An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery. Gastrointest Endosc. 2017;85:170–7.

    CAS  PubMed  Article  Google Scholar 

  55. 55.

    Hosmer A, Abdelfatah MM, Law RB. Endoscopic ultrasound-guided hepaticogastrostomy and antegrade clearance of biliary lithiasis in patients with surgically-altered anatomy. Endosc Int Open. 2018;6:E127–30.

    PubMed  PubMed Central  Article  Google Scholar 

  56. 56.

    James TW, Fan YC, Baron TH, Hill C, Carolina N. EUS-guided hepaticoenterostomy as a portal to allow defi nitive antegrade treatment of benign biliary diseases in patients with surgically altered anatomy. Gastrointest Endosc. 2019;88(3):547–54.

    Article  Google Scholar 

  57. 57.

    Moran RA, Ngamruengphong S, Sanaei O, Fayad L, Singh VK, Kumbhari V, et al. EUS - directed transgastric access to the excluded stomach to facilitate pancreaticobiliary interventions in patients with Roux - en - Y gastric bypass anatomy. Endosc Ultrasound. 2019;8:139–45.

    PubMed  Article  Google Scholar 

  58. 58.

    Irani S, Yang J, Khashab M. Mitigating lumen-apposing metal stent dislodgment and allowing safe, single-stage EUS-directed transgastric ERCP. VideoGIE. 2018;3:322–4.

    PubMed  PubMed Central  Article  Google Scholar 

  59. 59.

    •• Runge TA, Kowalski TE, Baron TH, Chiang AL, James T, Schlachterman A, et al. Living on the Edge - success, long term complication and implications following EUS-directed transgastric ERCP: a multicenter study. Gastrointest Endosc. 2019;89:AB 131Largest published data on EDGE including 178 patients which showed high technical and clinical success and 10% persistent fistula after 5 months post-stent removal which were successfully managed endoscopically.

    Article  Google Scholar 

  60. 60.

    Ngamruengphong S, Nieto J, Kunda R, Kumbhari V, Chen Y, Bukhari M, et al. Endoscopic ultrasound-guided creation of a transgastric fistula for the management of hepatobiliary disease in patients with Roux-en-Y gastric bypass. Endoscopy. 2017;49:549–52.

    PubMed  Article  Google Scholar 

  61. 61.

    Tyberg A, Nieto J, Salgado S, Weaver K, Kedia P, Sharaiha RZ, et al. Endoscopic ultrasound ( EUS ) -directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc. 2017;50:185–90.

    PubMed  Article  Google Scholar 

  62. 62.

    Wang TJ, Thompson CC, Ryou M. Gastric access temporary for endoscopy ( GATE ): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients. Surg Endosc. 2019;33:2024–33.

    PubMed  Article  Google Scholar 

  63. 63.

    •• Bukhari M, Kowalski T, Nieto J, Kunda R, Ahuja N, Irani S, et al. An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc. 2019;88:486–94 This study compared EDGE with DAE-ERCP and reported a higher technical success, shorter procedure time, and shorter hospital stay for EDGE, and comparable rates of AE for the two groups.

    Article  Google Scholar 

  64. 64.

    James TW, Baron TH. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a single-center US experience with follow-up data on fistula closure. Obes Surg. 2019;29:451–6.

    PubMed  PubMed Central  Article  Google Scholar 

  65. 65.

    Yang J, James T, Baron TH, Irani SS, Hsueh W, Nasr J, et al. EUS-guided creation of entero-enterostomy using lumen apposing metal stents for pancreatobiliary access in non-RYGB surgical anatomy patients. Gastrointest Endosc. 2019;89:AB642.

    Article  Google Scholar 

  66. 66.

    Shah RM, Tarnasky P, Kedia P. A review of endoscopic ultrasound guided endoscopic retrograde cholangiopancreatography techniques in patients with surgically altered anatomy. Transl Gastroenterol Hepatol. 2018;3:1–8.

    Article  Google Scholar 

  67. 67.

    • Kedia P, Tarnasky PR, Nieto J, Steele SL, Siddiqui A, Xu M, et al. EUS-directed transgastric ERCP (EDGE) versus laparoscopy-assisted ERCP (LA-ERCP) for Roux-en-Y gastric bypass (RYGB) anatomy: a multicenter early comparative experience of clinical outcomes. J Clin Gastroenterol. 2019;53(4):304–8 In this study, EDGE was found to be non-inferior to LA-ERCP in terms of efficacy and safety, with shorter procedure time and length of hospital stay.

    PubMed  Article  Google Scholar 

  68. 68.

    •• James HJ, James TW, Wheeler SB, Spencer JC, Baron TH, Hill C, et al. Cost-effectiveness of endoscopic ultrasound-directed transgastric ERCP compared with device-assisted and laparoscopic-assisted ERCP in patients with Roux-en-Y anatomy Authors. Endosc Ultrasound. 2019;51:1051–8 In this study, EDGE was found to be the most cost-effective modality for biliary interventions in post-RYGB anatomy, compared with LA-ERCP and DAE-ERCP.

    Google Scholar 

  69. 69.

    Khashab MA, Bukhari M, Chen YI, Brewer Gutierrez OI, Fayad L, Saxena P, et al. EUS-guided alteration of upper surgical anatomy to facilitate endoscopic management of biliary cast syndrome post liver transplantation. Gastrointest Endosc. 2017;85:AB114–5.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Mouen A. Khashab MD.

Ethics declarations

Conflict of Interest

Mouen A Khashab is a consultant for Boston Scientific, Olympus America, and Medtronic.

Nasim Parsa and Yervant Ichkhanian do not have any disclosures.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Endoscopy

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Parsa, N., Ichkhanian, Y. & Khashab, M.A. Endoscopic Retrograde Cholangiopancreatography in Patients With Surgically Altered Anatomy. Curr Treat Options Gastro 18, 212–231 (2020). https://doi.org/10.1007/s11938-020-00289-9

Download citation


  • Endoscopic retrograde cholangiopancreatography
  • Surgically altered anatomy
  • Device assisted enteroscope
  • New technologies
  • Endoscopic ultrasound guided antegrade intervention
  • EUS direct trans-gastric ERCP