Accessing the Pancreatobiliary Limb and ERCP

With the increasing number of bariatric procedures being performed for obesity, gastroenterologists will be faced with challenging situations in accessing the pancreatobiliary limb for ERCP due to surgically altered anatomy. There are a variety of techniques which can be used to reach the duct of interest—deep enteroscopy, endoscopic ultrasound-assisted, percutaneous, laparoscopic, or a combination of these. A clear understanding of the indication for ERCP and patient’s specific surgical anatomy is critical in achieving a successful outcome. High-volume centers with bariatric services should be aware of management options for patients with surgically altered anatomy in both elective and urgent situations. This chapter will review the available methods including devices and novel procedures for accessing the pancreatobiliary limb in bariatric patients.