Post written by Romik P. Srivastava, MD, from the Medical University of South Carolina, Charleston, South Carolina, USA.

In our video series, we present 4 cases of patients with non—gastric bypass altered anatomy who required complex ERCP. To facilitate peroral ERCP using a therapeutic gastroscope or duodenoscope, we created an EUS-guided enteroenterostomy in order to shorten the distance necessary to reach the bile duct. The video describes this technique in detail.

ERCP is technically challenging in patients with surgically altered anatomy. Multiple factors limit enteroscopy-assisted ERCP. In patients with Roux-en-Y gastric bypass anatomy, conventional peroral ERCP is now feasible using lumen-apposing metal stents (LAMSs). We applied the principles of EUS-guided anastomosis creation to facilitate complex peroral ERCP in patients without gastric bypass anatomy.

The approach to opacifying and distending the target loop of bowel for anastomosis in this procedure differs from that of EUS-directed transgastric ERCP. We hope that other endoscopists facing this difficult clinical scenario can use the examples provided in our video series.

We sincerely appreciate the opportunity to participate in GIE’s Endoscopedia discussion series.

Case 4: Endoscopic (A) and fluoroscopic (B) appearance of fresh gastrojejunostomy.

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