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Background Roux-en-Y gastric bypass (RYGB) surgery is one of the most commonly performed bariatric surgeries in the United States. Patients with prior RYGB are not amenable to conventional endoscopic retrograde cholangiopancreaticography (ERCP). Surgical gastrostomy (SG) tube placement enables transgastrostomy ERCP (TG-ERCP). Materials and Methods Eleven patients with RYGB anatomy received open Stamm gastrostomy after which the tract was then allowed to mature for an average of 45 days before therapeutic TG-ERCP. The success rate and procedure-related complications of both gastrostomy and ERCP were assessed. Results TG-ERCP was performed on eleven patients (median age 52 years, range 37–61 years) with prior RYGB and pancreatobiliary diseases. Indications for ERCP in these patients included suspected gallstone pancreatitis ( n  = 4), ampullary/biliary strictures ( n  = 5), pancreas divisum ( n  = 1), and common bile duct clipping as a result of RYGB surgery ( n  = 1). Two individuals developed post surgical complications with stomal-related infections. TG-ERCP with therapeutic intervention was successfully performed in all patients. Intervention included stone extractions ( n  = 11), biliary stricture dilation ( n  = 11), biliary sphincterotomy ( n  = 11), biliary ( n  = 3) and pancreatic ( n  = 1) stent placement, ampullary biopsies ( n  = 3), choledochoscopy ( n  = 1), and pseudocyst drainage ( n  = 1). Complications included post-ERCP pancreatitis ( n  = 2), post-sphincterotomy bleeding ( n  = 1), gastrostomy site bleed ( n  = 1), and gastric perforation ( n  = 1). The total number of ERCP sessions for the eleven patients was 15 (1 or 2 per patient). Median follow-up was 42 days (range 7–123 days). Conclusion Surgical open gastrostomy followed by TG-ERCP enables therapeutic intervention but is associated with significant complications.

It is increasingly recognized that patients with chronic liver disease have a reset hemostatic mechanism. This includes risks of both spontaneous and procedural bleeding, as well as inappropriate clotting, such as peripheral or portal vein thrombosis and small vessel thrombotic disease, possibly leading to hepatic parenchymal extinction and ultimately organ atrophy. Moreover, the conventional method of monitoring bleeding risk with prothrombin time/international normalized ratio is becoming recognized as an unreliable measure of bleeding (or clotting) risk in these patients. Herein, the coagulation mechanisms of patients with chronic liver disease and pitfalls of current practice are highlighted. A strategy to better identify and manage this challenging patient population in the setting of endoscopic interventions is proposed.

Pancreatic cancer is devastating due to its poor prognosis. Patients require a multidisciplinary approach to guide available options, mostly palliative because of advanced disease at presentation. Palliation including relief of biliary obstruction, gastric outlet obstruction, and cancer-related pain has become the focus in patients whose cancer is determined to be unresectable. Endoscopic stenting for biliary obstruction is an option for drainage to avoid the complications including jaundice, pruritus, infection, liver dysfunction and eventually failure. Enteral stents can relieve gastric obstruction and allow patients to resume oral intake. Pain is difficult to treat in cancer patients and endoscopic procedures such as pancreatic stenting and celiac plexus neurolysis can provide relief. The objective of endoscopic palliation is to primarily address symptoms as well improve quality of life.