An Alternative Route into the Biliary Tree Following Gastric Bypass Surgery

Abstract

We present a novel case with a combined procedure of laparoscopic cholecystectomy and laparoscopic-facilitated endoscopic retrograde cholangio-pancreatography (ERCP) in a patient who had previously undergone laparoscopic Roux-en-Y gastric bypass surgery 2 years earlier. At a follow-up bariatric clinic, 2 years postobesity surgery, this 50-year-old patient complained of right upper quadrant pain and nausea. Ultrasonography and magnetic resonance cholangio-pancreatography demonstrated multiple stones within the gallbladder and in the common bile duct (CBD). A planned joint procedure with the gastroenterologists was performed. Access to the abdomen was obtained via a subumbilical port inserted under direct vision. Pneumoperitoneum was obtained and four further ports were placed. The cystic duct was identified and cannulated, and an on-table cholangiogram was performed, which confirmed the presence of multiple stones in the distal CBD. However, only one stone was amenable to extraction via a Fogarty balloon trawl. As the CBD was too narrow for choledochotomy and CBD exploration, it was decided to proceed to laparoscopic gastrostomy and transgastric ERCP. The gastrostomy was fashioned in the remnant stomach and secured with a purse string suture. A 15-mm port was then inserted into the left upper quadrant and a side-viewing endoscope was introduced through this port into the gastrostomy. The duodenal papilla was identified and cannulated, and a cholangiogram reconfirmed stones in the CBD. A sphincterotomy was performed, followed by a balloon trawl and extraction of the gallstones. Completion cholangiogram demonstrated a clear biliary tree. Single layer closure of the gastrostomy and laparoscopic cholecystectomy was then undertaken. This patient made an uneventful recovery and was discharged home 2 days postprocedure. We suggest that this is a useful technique for the retrieval of stones in the biliary tree in patients who have had previous Roux-en-Y gastric bypass surgery. No competing financial interests exist. Runtime of video: 6 mins 52 secs