Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review

Figure 4 Endoscopic ultrasonography-directed transgastric endoscopic retrograde cholangiopancreatography for management of common bile duct stone in patient with previous Roux-en-Y gastric bypass for bariatric surgery. A: Endoscopic ultrasonography (EUS)-guided puncture of the excluded stomach with a 19G EUS needle with injection of contrast medium and sterile saline for gastric distension under fluoroscopic control; B: EUS guided first flange deployment of 20 mm lumen apposing metal stent (LAMS) into the gastric remnant; C: Endoscopic retrograde cholangiopancreatography for stone removal was performed after advancing the duodenoscope through the LAMS (green arrow); D: Endoscopic image confirming placement of the LAMS within the gastric pouch.