Endoscopic retrograde cholangiopancreatography in patients with roux-en-Y anatomy

Historically, Billroth II gastrectomy was the predominant surgically altered anatomy that fostered challenging endoscopic retrograde cholangiopancreatography (ERCP) procedures. Multiple studies reported excellent ERCP success using duodenoscope and forward viewing endoscopes including gastroscope and colonoscope in patients with Billroth II anatomy. In recent years, in response to the obesity pandemic in the United States, bariatric surgery has been on the rise and Roux-en-Y gastric bypass (RYGB) has become the preferred bariatric surgical method. RYGB anatomy poses a major challenge for endoscopists when biliary or pancreatic duct access is required given the long (often>100 cm) roux limb that must be traversed in order to reach the papilla. Roux-en-Y reconstruction is also commonly performed after gastrectomy or as part of choledochojejunostomy but such patients have shorter roux limbs compared to RYGB patients. ERCP procedures in rouxen-Y anatomy are among the most technically difficult and time consuming procedures performed by Gastroenterologists. There are a variety of strategies available for endoscopists to perform ERCP in patients with roux-en Y anatomy safely and effectively. This article reviews several of these strategies with an emphasis on those patients post Roux-en-Y gastric bypass.