<b><i>Background:</i></b> Alterations in the anatomy of the upper gastrointestinal tract may pose a challenge to the endoscopist, especially if interventions to the biliary system are indicated in patients with altered continuity of the gastrointestinal tract, impeding to reach the papilla with conventional ERC techniques. The success of any endoscopic intervention in this setting depends on optimal knowledge on the postoperative anatomy in each individual patient. <b><i>Summary:</i></b> If conventional endoscopic retrograde cholangiopancreaticography is impossible, biliary tree access can be achieved by applying novel techniques including endosonography-directed approaches, overtube-assisted approaches or spiral enteroscopy to reach the papilla or biliodigestive anastomosis in case of long limbs, percutaneous or even hybrid approaches. This review gives an overview of the most common techniques. <b><i>Key Message:</i></b> The choice of endoscopic approach should be individual in each patient, taking indication and urgency, type of anatomic alteration, local expertise, patients’ characteristics and preferences as well as prognosis into account. Early interdisciplinary discussion is essential to choose the procedure with the optimal risk-benefit ratio in the individual patient.