Endoscopic retrograde cholangiopancreatography (ERCP) in the patient with altered intestinal anatomy secondary to surgery presents significant challenges to the endoscopist. Navigating anastamoses, cannulation using a forward viewing endoscope in a retrograde position and use of specialized instruments encompass just a few of the unique issues which arise when attempting ERCP in patients with surgically altered anatomy. This article focuses on instruments, technique and a review of the published literature to date on performing ERCP in this group of patients.