Biliary drainage in patients with altered anatomy: Literature review of different endoscopic approaches

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy remains a challenging field in therapeutic endoscopy due to the complex anatomical reconstructions that limit access to the biliary tree. Over the past two decades, device-assisted enteroscopy (DAE), including single-balloon, double-balloon, and motorized spiral enteroscopy, has expanded the feasibility of ERCP in this population, with overall technical success rates generally reported between 70% and 90%. Nevertheless, these techniques are technically demanding, time-consuming, and frequently affected by limited reach and unstable positioning. More recently, interventional endoscopic ultrasound (EUS)-guided procedures have emerged as highly effective alternatives, significantly improving clinical outcomes in selected patients, particularly in those with long-limb Roux-en-Y reconstructions where conventional methods are less effective. Percutaneous transhepatic biliary drainage continues to represent a valuable salvage option when endoscopic approaches fail, though it is associated with a greater burden of reinterventions and adverse events. This minireview provides a comprehensive overview of the main endoscopic strategies for biliary drainage in altered anatomy, focusing on technical considerations, efficacy, and safety profiles of DAE-assisted ERCP, EUS-guided interventions, and motorized systems. The evolving landscape of biliary drainage in this setting highlights the need for tailored treatment strategies, multidisciplinary collaboration, referral to high-volume centers, and further prospective studies to refine patient selection and optimize clinical outcomes.