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 |