Endoscopic retrograde cholangiopancreatography (ERCP) is an important technique for the diagnosis and treatment of biliary and pancreatic disorders. ERCP in the patients with surgically altered anatomy (SAA) is more technically demanding with high risks of procedural failure and complications, and it is challenging for the endoscopists. Recently, the development of endoscopic devices and the improvement of operator skills have led to SAA-ERCP progresses. The success rate of ERCP and the incidence of complications are similar to those of the patients with normal anatomy. This paper reviews the recent advances on SAA-ERCP, including the effectiveness and safety, and endoscopy and assisted techniques, and summarizes the clinical features of SAA-ERCP.