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©2013 UpToDate ® Print Email 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.