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Obese and post-Roux-en-Y gastric bypass (RYGB) patients are at increased risk of cholelithiasis and associated biliary disorders [1–3]. Because of the complicated postsurgical anatomy, endoscopic retrograde cholangiopancreatography (ERCP) may be more difficult, requiring deep enteroscopy or laparoscopic assistance. We report a case of intentional disruption of the gastric remnant-excluded stomach staple line to gain access to the duodenum for treatment of choledocholithiasis. A 72-year-old woman with past medical history of recent four-vessel cardiac artery bypass, oxygen-dependent chronic obstructive pulmonary disease, dialysis-dependent end-stage renal disease, and RYGB with cholecystectomy 30 years ago was admitted at a local hospital with gallstone pancreatitis. She was treated with typical therapy and clinically improved, but on hospital day 3 she was noted to have a persistently elevated total bilirubin of 2.7mg/dL. Magnetic resonance pancreatography (MRCP) showed a dilated common bile duct (12mm) with choledocholithiasis. ERCP was attempted at the local facility, but failed as the jejuno-jejunal anastomosis could not be reached, prompting transfer to our facility. On repeat ERCP, we accessed to the jejuno-jejunal anastomosis, which was deepFig.2 Fluoroscopic image of cannulatome and wire through staple line fistula into excluded stomach.

Another option for biliary access in post-bypass patient: intentional disruption of a gastric staple line