currently for super - obese individuals , bariatric surgery is the only evidence - based approach that results in clinically significant and sustainable weight loss . with the increasing prevalence of obesity , there is an increased demand for bariatric surgery .
subsequently , a large number of patients shall be presenting with the complications of bariatric surgery .
a 42-year - old caucasian female underwent laparoscopic roux - en - y gastric bypass in february 2007 .
she subsequently developed gallstones , a known complication of bariatric surgery due to rapid weight loss .
she presented to our unit in february 2012 with a week long history of right upper quadrant pain associated with vomiting .
blood tests revealed deranged liver function tests : alkaline phosphatase of 169 u / l and alanine aminotransaminase of 188 u / l .
a computed tomographic scan was organized confirming the appearances of a dilated common bile duct and the potential of a calcified stone in the common bile duct .
she was managed conservatively with analgesia and ursodeoxycholic acid to attempt to dissolve the stones .
her liver function tests and pain improved , and she was discharged with an outpatient magnetic resonance cholangiopancreatography ( mrcp ) . in march 2012 ,
her mrcp showed a dilated common bile duct of 10 mm and two small filling defects suggestive of gallstones .
again , this confirmed the dilated common bile duct , but also showed free drainage of bile into the duodenum and no gallstones ; hence , therapeutic interventions were not undertaken .
she was referred to the gastroenterologists for further advice , but as of june 2012 she was still symptomatic .
ultimately , an endoscopic retrograde cholangiopancreatography ( ercp ) and sphincterotomy was deemed to be necessary to alleviate her symptoms .
owing to the altered anatomy post roux - en - y gastric bypass , this was to be a technical challenge .
the bypass of the distal stomach and proximal small bowel is achieved by anastomosis of the gastric pouch and the jejunum known as the roux alimentary limb .
the biliary pancreatic limb is then anastomosed to a small bowel . as a result it is technically challenging to perform an ercp in the conventional manner ,
two subsequent port sites were used : a 5-mm port site in the right upper quadrant and a 10-mm port in the left hypochondrium ( fig .  1 ) . 

stay sutures were placed in a diamond - shaped configuration around the gastrotomy site  these can allow both traction and counter - traction .
a sterile ercp scope inserted manually through a left 10-mm port site all under laparoscopic visualization .
there were no obvious gallstones in our patient ( fig .  2 ) . 

the gastrotomy site was closed with a two layer closure : the first layer as a running stitch and then as a horizontal mattress with 2.0 vicryl .
she was admitted for an overnight stay and discharged the following day . upon review of the patient in a routine 6-week follow - up clinic , she was asymptomatic and was discharged back to the care of her general practitioner .
with the increased demand for bariatric surgery worldwide , there will be an increased role of endoscopy to diagnose and manage complications . with altered anatomy , the transgastric approach can be used as an access point into the gastrointestinal tract .
we have demonstrated that the technique when performed correctly can be a safe and viable option in most district general hospitals , which would certainly have a laparoscopic surgeon and a gastroenterologist on site .
 the prevalence of bariatric surgery is increasing worldwide and as a direct consequence , there shall be an increasing number of patients presenting with the complications of bariatric surgery , often to non - specialist units . 
 the authors report a case of a 42-year - old caucasian female who had previous laparoscopic roux - en - y gastric bypass , open cholecystectomy and abdominoplasty presenting with right upper quadrant pain in keeping with retained common bile duct stones . after the failure of conservative management , a laparoscopic - assisted transgastric endoscopic retrograde changiopancreatography and sphincterotomy was performed . 
 we shall be describing our technique . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST STATEMENT