Nikhil A. Kumta, MD from the Division of Gastroenterology and Hepatology at Weill Cornell Medical College in New York, New York, USA presents this video case, “Bypassing the bypass: EUS-directed transgastric ERCP for Roux-en-Y anatomy.”

Patients with altered anatomy from a Roux-en-Y gastric bypass pose distinct challenges to performing endoscopic retrograde cholangiopancreatography (ERCP). In this video, we describe an alternative endoscopic approach that uses endoscopic ultrasound (EUS) to gain percutaneous gastrostomy access to the excluded stomach in patients with Roux-en-Y gastric bypass anatomy.

EUS-directed transgastric ERCP (EDGE) is divided into 2 stages performed during separate endoscopic sessions. The first stage of the procedure involved placement of a 16F percutanous gastrotomy tube into the excluded stomach under EUS guidance. During the second stage, ERCP is performed in an antegrade fashion through the fashioned gastrostomy after replacement of the gastrostomy tube with a transcutaneous, fully covered, metal esophageal stent. In our experience with 6 patients, EUS-guided access to the excluded remnant stomach was successful in all 6 patients (100%). Antegrade ERCP was successfully performed in all 6 patients (100%), with a mean 5.8 days between the 2 stages.

This video highlights a new technique to perform an ERCP in patients with altered anatomy from Roux-en-Y gastric bypass.

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