An Emerging Problem: Multidisciplinary Treatment of Liver Transplant-Associated Biliary Complica- tions in Patients with Roux-En-Y Gastric Bypass

Introduction: There is an increasing number of patients with a history of both liver transplantation (LT) and Roux-en-Y gastric bypass (RYGB). Biliary tract complications are the most prevalent LT-associated complication, with endoscopic retrograde cholangiopancreatography (ERCP) as the preferred therapeutic approach. However, surgically altered anatomy after RYGB renders ERCP technically challenging. This overview attempts to address, through real-life practical cases, the various available approaches for the management of biliary tract complications in LT patients with RYGB. Methods: Descriptive single Center overview of endoscopic treatment modalities of biliary tract complications in LT recipients with a history of RYGB. Different techniques are discussed and illustrated with clinical cases. Results: Balloon enteroscopy-assisted-ERCP (BE-ERCP), endoscopic ultrasound (EUS)-directed trans gastric endoscopic retrograde cholangiopancreatography (EDGE), percutaneous trans hepatic biliary drainage (PTBD), or a combination of these procedures can be used according to the clinical indication or the surgical reconstruction of the bile duct (biliary duct end-to-end anastomosis vs hepaticojejunostomy) in conjunction with RYGB. Case 1 was treated with PTBD, followed by BE-ERCP; case 2 was treated with BE-ERCP, followed by EDGE; case 3 was treated with PTBD, followed by EDGE; and case 4 was treated with BE-ERCP. Conclusion: Both BE-ERCP, EDGE and PTBD in different combinations are promising endoscopic therapeutic approaches for treating LT-associated biliary tract complications in RYGB patients. Since the number of these patients with combined LT and RYGB is expected to increase, more studies focusing on this specific population are warranted to comprehensively assess the efficacy and safety profiles of these interventions.