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A 67-year-old woman with history of Roux-en-Y gastric bypass presented for management of acute cholangitis. Magnetic resonance cholangiopancreatography (MRCP) demonstrated extrahepatic bile duct dilatation. The results of her liver chemistry tests were aspartate aminotransferase (AST) 156 IU/L, alanine aminotransferase (ALT) 182 IU/L, total bilirubin 2.6mg/dL, and alkaline phosphatase 319IU/L. The patient underwent transgastric endoscopic retrograde cholangiopancreatography (ERCP) using a modified technique merging percutaneous assisted transprosthetic endoscopic therapy (PATENT) [1] and endoscopic ultrasound (EUS)-guided sutured gastropexy for transgastric ERCP (ESTER) [2] (●" Video 1). An oblique-viewing, linear array echoendoscopewas passed into the gastric pouch to identify the excluded gastric remnant. The gastric remnant was punctured with a 19G fine needle aspiration (FNA) needle (●" Fig.1). Contrast injection confirmed entry of the needle into the excluded stomach. Air (500mL) was infused through the FNA needle to distend the gastric remnant. After the remnant was adequately distended, a 19G percutaneous access needle was used to create a gastrostomy. A 450-cm, 0.035-inch biliary guidewire was passed into the excluded stomach and subsequently into the duodenum. The percutaneous access needle was removed leaving the guidewire in place. Three T-fasteners were secured around the guidewire. Graduated dilation of the gastrostomy tract up to 18Fr was performed. A fully covered esophageal selfexpandable metal stent (SEMS; 20mm× 6cm) was deployed within the gastrostomy tract. The SEMS was dilated to 18mm using a high burst pressure balloon dilator. A standard therapeutic duodenoscope was then passed through the SEMS. The bile duct was selectively accessed and cholangiography was performed (●" Fig.2). Sphincterotomy was followed by sludge removal with an extraction balloon. Following ERCP, a 20-Fr replacement gastrostomy tube was placed. The SEMS was sectioned and removed. No adverse events occurred. The total procedure time was 80 minutes. The patient was pain-free and was discharged home 2 days later. Repeat laboratory tests 4 days later revealed AST 62 IU/L, ALT 146 IU/L, total bilirubin of 1.2mg/dL, and alkaline phosphatase 304 IU/L. Removal of the gastrostomy tube was planned for at least 6 weeks after the procedure.

Modified percutaneous assisted transprosthetic endoscopic therapy for transgastric ERCP in a gastric bypass patient