Laparoscopic-Assisted Transgastric ERCP in Patients with Gastric Bypass: Unique as an Odd Duck

Abstract

Laparoscopic assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) is used for treatment in patients after gastric bypass, where transoral access to the biliary tree is not possible. We describe our technique and experience with this procedure for our patient who had undergone Roux en y gastric bypass (RYGB). Patient underwent intra-operative cholangiography which revealed common bile duct (CBD) stones. A combined laparoscopic-endoscopic approach was attempted. A small gastrotomy with a purse-string suture was performed on the anterior wall on remanant stomach. A side-viewing scope was introduced through a 15-mm trocar on the upper left quadrant and through the gastrotomy. The jejunum was occluded to prevent air passage and small bowel distension. Endoscopic sphincterotomy and stone extraction were carried out according to standard techniques. Occlusion cholangiogram confirmed CBD clearance. There was no procedure-related complication, and the patients were discharged on the second postoperative day. The patient was doing well at 1-year follow-up. Biliary obstruction can occur many years after gastric bypass with or without cholecystectomy. Our findings suggest that gastric bypass patients may be at a higher risk of symptomatic cholelithiasis with CBD stones. LAERCP is a reliable option for common bile duct clearance; our technique of LAERCP is technically simple and associated with low complication rate, making it appealing to surgeons trained in laparoscopy.