Post written by Ryan Law, DO, from the University of Michigan, Ann Arbor, Michigan.

In our case presentation we describe a patient who presented to our institution with concern for biliary pathology in the setting of prior Roux-en-Y gastric bypass with an indwelling percutaneous biliary drain. Importantly, this patient underwent a sleeve gastrectomy prior to her gastric bypass, thus making options such as intraoperative ERCP or ERCP via an EDGE procedure unlikely to succeed. Given the dismal success rate of balloon enteroscopy-assisted ERCP, we elected to perform and EUS-guided side-to-side jejunojejunostomy to facilitate ERCP at a follow-up procedure. ERCP was ultimately successful, and the percutaneous biliary drain was removed without incident.

Endoscopists need to be aware if a patient underwent sleeve gastrectomy prior to gastric bypass. This will certainly be a limiting factor if pancreaticobiliary issues present as more conventional and innovative options will be limited. Additionally, we showed that this approach can be utilized successfully under these circumstances but requires forethought regarding the positioning of the LAMS to best facilitate ERCP in the future.

The importance of a good surgical history and thoroughly reviewing prior operative notes is paramount in therapeutic endoscopy. Forethought spares afterthought.

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