ERCP in patients with Roux-en-Y anatomy: Approach to biliary access

This figure summarizes an approach to reaching the intraluminal biliary access point in patients with Roux-en-Y anatomy. Indications for ERCP in this patient population may include biliary obstruction from common bile duct stones or biliary stricture. Selecting a technique is also informed by the available resources including expertise in endoscopic ultrasound, device-assisted small bowel enteroscopy, and laparoscopic surgery. Refer to content on ERCP in patients with surgically-altered anatomy for additional details, including techniques for selective ductal cannulation.

ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic ultrasound.

* In patients with a native papilla, the Roux limb refers to the alimentary limb.

¶ Another approach to accessing the excluded stomach is percutaneous-assisted transprosthetic endoscopic therapy (PATENT), although this technique has not been widely used in clinical practice. PATENT involves the use of device-assisted (balloon) small bowel enteroscopy or EUS to access the excluded stomach followed by placement of a percutaneous gastrostomy tube. Next, a self-expandable metal sent is deployed within the gastrostomy tract, and then ERCP is performed through the stent.

Δ For patients with bilioenteric anastomosis, forward-viewing endoscopes (eg, small bowel enteroscope, small caliber colonoscope) are usually adequate for establishing access to the bile ducts.

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ERCP in patients with Roux-en-Y anatomy: Approach to biliary access