Endoscopic Ampullectomy to Gain Access in CBD in a Patient with RNY Gastric Bypass Surgery

Abstract

Figure: No Caption available.Purpose: A 55-year-old white female with RNY gastric bypass presented with complaints of puritus for 3 months. Liver test was noted grossly abnormal with predominant choestatic pattern. MRI/MRCP showed grossly dilated intra- as well as extra-hepatic biliary channels. CBD dilated to 14 mm with smooth distal narrowing suggestive of stricture. No filling defects in CBD or any ampullary or pancreatic mass seen. ERCP was performed with pediatric colonoscope, ampulla was reached via afferent limb. A large ampullary mass was found. Attempt to cannulate CBD failed, mass was partially resected with snare, tissue collected and histology showed adenoma with no high-grade dysplasia. Once ampullary carcinoma was ruled out, a few weeks later repeat ERCP was performed successfully and the following key steps are demonstrated in the video: 1.) successful CBD cannulation, stent deployment; 2.) needle knife papillotomy; 3.) ampullectomy with hot snare in piecemeal fashion; 4.) stent removal; 5.) balloon dilation of the stricture and sphincteroplasty; and 6.) balloon sweep. Complete procedure was recorded and later edited to include only key elements of the procedure. No attempt was made to cannulate pancreatic duct. Post ERCP, patient was observed overnight in the hospital. No post-ERCP pancreatitis occurred. Patient was followed in clinic regularly, pruritus completely resolved, and liver test slowly normalized. Endoscopic ampullectomy in RNY gastric bypass patient is technically challenging; however, this can be performed by experienced therapeutic endoscopists working at high-volume pancreatic-biliary centers.