Management of Common Bile Duct Stones in the Presence of Prior Roux-en-Y

Roux-en-Y (RNY) intestinal anatomy is increasingly common among several unique patient populations. RNY gastric bypass for weight loss is the prototypical example. RNY foregut anatomy precludes facile transoral access to the papilla by endoscopic retrograde cholangiopancreatography (ERCP), and alternative techniques to access must be established for biliary access to treat stones and other disease processes. The technique used for management of choledocholithiasis in the presence of RNY depends on several factors, including the clinical stability of the patient, stone size, local equipment availability, and technical expertise of proceduralists. This chapter reviews the current endoscopic, percutaneous, surgical, and various hybrid techniques which are available to treat stones and biliary diseases after prior RNY.