Treatment of benign biliary obstruction is a challenging situation in patients with altered anatomy. ERCP with single or double balloon enteroscopy can be difficult, with an overall cannulation success of about 60%. We describe the case of a 86-years old women with history of 4/5 gastrectomy and Roux-en-Y anastomosis and main bile duct symptomatic lithiasis, with failure of two enteroscopies. After performing hepaticogastrostomy, we performed an anterograde electrohydraulic lithotripsy using an ultraslim videogastroscope as a cholangioscope. A guidewire was placed during cholangioscopy to place a transpapillary biliary metallic stent to enable complete biliary stones clearance.
