Roux-en-Y gastric bypass (RYGB) remains the most commonly performed surgical laparoscopic procedure worldwide to treat morbid obesity. The incidence of biliary stones formation after bariatric surgery is higher than in the overall population due to the rapid weight loss. If this occurs, the Roux-en-Y anatomic configuration makes the management of stone pathology challenging because traditional ERCP is not feasible.

Several endoscopic approaches are available to gain access to the biliary tree in patients after RYGB.

Enteroscopy technique allows deeper access to the duodenum but can be particularly challenging or technically impossible as the area of the papilla can only be reached by a retrograde progression of the endoscope along the Roux-en-Y loop. Nevertheless, this technique is time consuming, and currently, there are reduced toolsets for therapeutic intervention.

EUS-guided biliary drainage is a technically challenge procedure and could be an option only in referred center.

Recently EUS-guided gastro-gastric anastomosis with the placement of a lumen apposing metal stent has been introduced to create the access to the excluded stomach and to reach the papilla with a normal duodenoscope.

Another alternative is the laparoscopy assisted ERCP which is conducted with a side-view duodenoscope that is introduced through the trocar in a laparoscopic access to the remnant stomach. As an alternative the gastrostomy can be fixed to the skin. In both procedures the surgical access to the excluded stomach allows the duodenoscope to reach the papilla.