Intraoperative transgastric ERCP after a Roux-en-Y gastric bypass

Roux-en-Y gastric bypass (RYGB) is among the favorite surgical approaches to treating morbidly obese patients, but leads to an increased incidence of choledocolithiasis. Per-oral endoscopic retrograde cholangiopancreatography (ERCP) represents a major challenge in this situation [1] [2]. ERCP through a surgically placed gastrostomy has been proposed as an alternative route for endoscopic access [3] [4] [5]. We report a case of endoscopically treated choledocolithiasis via a transgastric approach during laparoscopic cholecystectomy in a RYGB patient.

A 30-year-old woman underwent a RYGB procedure. Preoperative ultrasonography identified only hepatic steatosis. At 7 months after surgery and a 38 kg weight loss, abdominal ultrasound was performed because of noncharacteristic abdominal pain. Cholelithiasis was identified, and a laparoscopic cholecystectomy was planned.

Intraoperative cholangiography revealed common bile duct (CBD) stones, and only partial ductal clearance was achieved ([Figure 1]). A combined laparoscopic-endoscopic approach was attempted. A small gastrotomy with a purse-string suture was performed on the anterior wall. A duodenoscope was introduced through a 15 mm trocar on the upper left quadrant and through the gastrotomy ([Figure 2] a and b). The duodenum was occluded to prevent air passage and small bowel distension. Endoscopic sphincterotomy and stone extraction were carried out according to standard techniques ([Figure 3] and [4]). Occlusion cholangiogram confirmed CBD clearance. There was no procedure-related complication, and the patient was discharged on the second postoperative day. The patient is doing well at 8-months’ follow up.

Transgastric laparoscopic-assisted ERCP in the management of cholelithiasis in RYGB patients is technically feasible and apparently not associated with a higher complication rate. Its one-step nature may reduce hospital stay and costs.

Figure 1 Intraoperative cholangiography after attempt to remove common bile duct stones.

Figure 2 a, b Duodenoscope introduced through a 15 mm trocar placed on the upper left quadrant and through the gastrotomy.

Figure 3 Duodenoscope and sphincterotome in place, immediately before sphincterotomy.

Figure 4 Removal of stone fragments with the extractor balloon from the common bile duct.

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References

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• 4 Pimentel R R, Mehran A, Szomstein S. et al . Laparoscopy-assisted transgastrostomy ERCP after bariatric surgery: case report of a novel approach.  Gastrointest Endosc. 2004;  59 325-328
• 5 Matlock J, Ikramuddin S, Lederer H. et al . Bypassing the bypass: ERCP via gastrostomy after bariatric surgery.  Gastrointest Endosc. 2005;  61 AB98