Post written by Kambiz S. Kadkhodayan, MD, from the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.

We describe 2 patients with Roux-en-Y gastric bypass (RYGB) who underwent double-balloon enteroscopy—assisted ERCP (DBE-ERCP) for the management of pancreatolithiasis and choledocholithiasis.

After reaching the ampulla, deep cannulation of the bile duct could not be achieved using the enteroscope. Both patients subsequently underwent same-session EUS-guided rendezvous, and biliary access was successfully achieved.  

Achieving deep cannulation of the common bile duct (CBD) can be technically challenging when using an enteroscope. Advanced cannulation techniques such as precut-needle-knife access are generally reserved for challenging cases.

When advanced cannulation fails, patients with RYGB have traditionally been referred to interventional radiology or, in centers with EUS expertise, a staged EUS-directed transgastric ERCP is performed with the hope of cannulating the CBD using the broader array of available ERCP instruments.

In patients with unaltered foregut anatomy, EUS-guided rendezvous is a commonly used option at this juncture. EUS-guided rendezvous is not commonly used in the setting of RYBG because of perceived procedural complexity.

We demonstrate successful EUS-guided rendezvous in 2 patients with RYGB, in whom retrograde access to the CBD was not achieved via DBE-ERCP. We believe that EUS-guided biliary access should be considered a viable option for patients with RYGB, provided the ampulla can be reached via balloon-assisted enteroscopy.

I would like to thank GIE for the opportunity.

Bevel-shaped sphincterotome tip modification used for rendezvous. A, The yellow line depicts the angle at which to trim the tip of the sphincterotome. Of note, the side opposite the cutting wire is trimmed. Side view (B) and front view (C) of a completed bevel-shaped sphincterotome modification.

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