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This review highlights the current status of endoscopic retrograde cholangiopancreatography (ERCP) techniques in patients with altered anatomy. Endoscopic treatment of biliopancreatic disorders is particularly challenging in patients with altered anatomy.There are two main approaches to perform ERCP in patients with altered anatomy: the transluminal access and the transmural access. The transluminal access uses device-assisted enteroscopy (DAE) to reach and cannulate the biliopancreatic system. The transmural access is created using therapeutic endoscopic ultrasound (EUS) or surgery to reach the biliopancreatic system. Both techniques are under continuous development and optimization.Based on the currently available data in the literature, the transluminal access is the preferred first-line approach because of an acceptable success rate and an excellent safety profile, whereas the transmural approach may be more efficacious but with a higher complication rate, even in experienced hands. Due to the complexity of both techniques and the relative low number of procedures, patients with altered anatomy are best referred to high-volume centres where both techniques are available for optimal treatment.