Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography in twice-surgical heart rate anatomy scenario. About one-third of post-bariatric patients develop Galstons due to the increased lithogenicity following weight loss. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography is increasingly used to access the ampullary region in patients receiving Rhen Y gastric bypass. A 30-year-old woman with a former history of slitted gastrectomy subsequently converted to Rhen Y gastric bypass was admitted for bilary colic. Endoscopic resonance showed multiple common bile duct stones. After explanation of all alternatives, endoscopic ultrasound-directed transgastric ECP was proposed. From the post-anastomotic jejunum, following the duodenum backwards, a small ancient remnant with sand-on-dollar sign was identified. A jejunum gastrostomy was created by free-end deployment of 20x10 mm electrocauterion-enhanced lumen-opposing metal stand, after filling the antrum with contrast medium solution. After two weeks, through-the-lumps ERCP with stone extraction was performed. After two months, the lumps was removed, and the edges of the jejunum gastric fistula were treated by argon-plasma coagulation. In this magnetic resonance cholangiopancreatography picture, you can see the bilary stones into the common bile duct. After a U.S. exploration from the gastric pouch, the post-anastomotic jejunum was intubated. The U.S. identified the pancreatic head and bilary stones, thus following back the duodenum, the antrum remnant was identified. The antrum remnant was pancreated with a 90 gauge needle. The antrum remnant was injected with saline mixed with contrast medium, which flowed through the pylorus into the duodenum. After adequate loop distension, a freehand 20 mm lumps was advanced and deployed. The patient was discharged and readmitted after 14 days, for through-the-lumps ERCP. The lumps was anchored through endoclips. The loop was intubated with a standard duodenoscope and the lumps was transversed under endoscopic and radioscopic guidance. The pylorus was immediately downstream and was transversed. In the duodenum, the endoscope was pulled into a short position. A standard ERCP with sphincterotomy and balloon swipe was performed. Final occlusion cholangiography showed complete duct clearance. After two months, the patient underwent through-the-lumps diagnostic U.S. and subsequent lumps removal. From the bulb, U.S. showed undulated common bile duct with no biliary stone. From the second dodenal portion, U.S. showed normal pancreatic head and common bile duct. The lumps was removed. The jejunogastric fistula was treated with argon plasma coagulation to favor spontaneous closure. Endoscopic ultrasound-directed transgastric ERCP is a safe and effective approach for diagnostic and therapeutic pancreatobiliary interventions in Rheum Y gastric bypass patients. Former sleeve gastrectomy makes the antrum remnant smaller and dislocated, yet still accessible from the post-anastomotic jejunum with some technical tricks.

endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography

Rhen Y gastric bypass surgery

sleeve gastrectomy

common bile duct stones

pancreatobiliary interventions