An unusual complication following endoscopic ultrasound-directed transgastric ERCP in a patient with a history of bariatric surgery

We present the case of a 56-year-old woman with a history of sleeve gastrectomy and gastric bypass who developed an atypical complication following gastro–gastric anastomosis during an endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) procedure (EDGE) to access the biliary tract. The patient had undergone sleeve gastrectomy followed by gastric bypass 7 years previously for severe gastroesophageal reflux disease. She was referred to our center for management of symptomatic biliary tract stones. EUS confirmed the presence of biliary lithiasis and EDGE was planned for biliary access.