Accessing the pancreatobiliary limb and ERCP in the bariatric patient

The Roux-en-Y gastric bypass (RYGB) accounts for more than 60% of bariatric procedures performed in the United States today. The RYGB anatomy poses particular challenges to interventional endoscopists who intend to access the papilla. Deep enteroscopy-assisted endoscopic retrograde cholangiopancreatography seems to be the least invasive technique for this purpose, and is often the best initial choice. However, considerable experience is needed to optimize the success rate of reaching the biliopancreatic limb, with subsequent successful cannulation, and which approach is taken should be determined on a case-by-case basis.