Background: Pancreatobiliary access following Roux en Y Gastric Bypass(RYGBP)is challenging. We present the largest series to date, evaluating 32 cases of surgical gastrostomy for endoscopic upper gastrointestinal endoscopy.Methods: Retrospective chart review of prospectively collected data on patients with history of previous RYGBP that between, 2004-2008, had laparoscopic or open gastrotomy for pancreatobiliary and duodenal access at a single institution. Data reviewed was indication for procedure, surgical findings, successful cannulation and complications.Results: Thirty patients (25 female) with age ranging from 27 to 72, underwent 32 procedures. The indications to access the gastric remnant were: 3 cholangitis, 13 sphincter of Oddi dysfunction, 5 common bile duct stone/obstruction, 6 pancreatitis, 1 cystic duct leak after cholecystectomy, 2 for pancreatic mass evaluation and 2 for gastrointestinal bleed. Mean operative time was 200 minutes(98-338), estimated blood loss, mean 85cc (10-500). 28 patients had laparoscopic gastrostomy with one conversion to open due to decreased visualization from gaseous distention of the small bowel after the ERCP and 4 open procedures. All 30 patients underwent successful cannulation, 28 had an ERCP, 2 patients had an EGD and 2 patients had an EUS. During surgical exploration 13 internal hernias were found in 10 patients: 7 Peterson hernias, 5 small bowel mesenteric defect and 1 transverse mesocolic defect. Surgical complications included: 1 patient had a wound infection at the gastrostomy tube site and 3 patients had to be re-explored. One had an abscess around the gastrostomy tube site and the other 2 patients had small amount of free fluid with no leak noted.Conclusions: Surgical gastrostomy is a safe and effective means to gain access to the upper GI tract following roux-en-Y gastric bypass. Given the incidence of unsuspected intra-abdominal hernias and the occasional need for open exploration, this procedure should be performed by experienced minimally invasive and pancreatobiliary surgeons.