Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography procedure for choledocholithiasis after sleeve gastrectomy and Roux-en-Y

The endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) procedure (EDGE) is employed when patients have altered anatomy from Roux-en-Y bypass surgery for treatment of biliary pathology. The procedure involves placing a lumen-apposing metal stent (LAMS) from the gastric pouch into the excluded stomach to create a fistula in which an ERCP scope can traverse to reach the ampulla [1]. However, patients who have previously undergone sleeve gastrectomy and Roux-en-Y bypass have a significantly smaller anatomical field to manipulate, which poses a technical challenge for the endoscopist. The case we report here shows that EDGE can be performed successfully using a gastro–gastric approach ([Video 1]).