Approaches for ERCP in patients with Roux-en-Y anatomy

Technique	Advantages	Disadvantages	Best application
Duodenoscope advanced transorally through anatomic route	Ideal instrument for cannulation and therapy of native papilla Minimally invasive	Frequently unsuccessful due to inability to reach target	Patients with short Roux limb and native papilla
Colonoscope/enteroscope advanced transorally through anatomic route	Greater depth of insertion compared to duodenoscope Minimally invasive	Frequently unsuccessful in patients with long Roux limb Forward view Lack of elevator	Patients with short Roux limb and bilioenteric/ pancreatoenteric anastomosis
Deep enteroscopy assisted ERCP	Greater reliability in reaching target, even in patients with long Roux limb	Forward view Lack of elevator Limited availability of accessories and instruments	Patients with long Roux limb and bilioenteric/ pancreatoenteric anastomosis
Transgastrostomy tract ERCP	Allows use of side viewing duodenoscope and all standard accessories Provides reliable access for repeat procedures	More invasive than purely endoscopic techniques	RYGB patients with native papilla, or when repeated procedures are anticipated
Laparoscopy-assisted ERCP	Allows use of side viewing duodenoscope and all standard accessories Ability to diagnosis and treat internal hernias	More invasive than purely endoscopic techniques Requires significant coordination between surgery and endoscopy teams	RYGB patients with native papilla, particularly when internal hernia is suspected
Percutaneous approaches via interventional radiology	Less invasive than surgical approaches	Morbidity (pain, external drains) No access to pancreas	Patients with biliary tract pathology who are poor surgical candidates

ERCP: endoscopic retrograde cholangiopancreatography; RYGB: Roux-en-Y gastric bypass.

Original figure modified for this publication. Lopes TL, Wilcox CM. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Gastroenterol Clin North Am 2010; 39:99. Illustration used with the permission of Elsevier Inc. All rights reserved.

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Approaches for ERCP in patients with Roux-en-Y anatomy