Feasibility and Safety of Endoscopic Peroral Cholangioscopy in Surgically Altered Anatomy: A Systematic Review and Meta-Analysis.

Background/

Objectives

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) presents significant technical challenges due to altered bowel reconstructions. Endoscopic peroral cholangioscopy (POC) offers a less invasive alternative to percutaneous or transmural techniques, but robust evidence validating its performance in SAA is lacking. This systematic review and meta-analysis (SRMA) aims to evaluate the feasibility and safety of endoscopic POC as a primary strategy in SAA.

Methods

A systematic search was performed on PubMed and Embase up to December 2025 for studies reporting cholangioscopic outcomes in SAA patients utilizing an endoscopic approach. The primary outcome was the cholangioscopic access rate (AR). Secondary outcomes included endoscopic success rate (SR), technical SR, and adverse events. Pooled rates were calculated using Generalized Linear Mixed Models (GLMM).

Results

Eight studies comprising 469 patients were included. The pooled endoscopic SR was 86.7% (95% CI, 74.4-93.6%) but showed high heterogeneity (I2 = 79.9%), largely driven by the variation in anatomical reconstructions. Subgroup analysis revealed higher endoscopic SR in short-limb anatomies (86.5%) compared to long-limb configurations (76.2%). Conversely, once biliary cannulation was achieved, the procedure was highly reliable: the pooled cholangioscopic AR was 95.9% (95% CI, 78.7-99.3%), with no significant difference across anatomical subgroups. The pooled adverse event rate was 3.1% (95% CI, 1.3-6.8%), predominantly characterized by mild complications.

Conclusions

Endoscopic POC is a feasible and safe technique for managing biliary disease in SAA. The procedure's overall success appears to be strictly dependent on the ability to navigate the altered anatomy (endoscopic phase), whereas the cholangioscopic phase itself proves highly effective and reproducible once biliary access is secured.