Laparoscopic transgastric endoscopy after Roux-en- Y gastric bypass

Abstract

Background Access and endoscopic evaluation of the bypassed stomach is difficult after laparoscopic Roux-en- Y gastric bypass. We propose a minimally invasive technique to access the bypassed stomach after Roux-en- Y gastric bypass for endoscopic diagnosis and treatment. Methods First, we established carbon dioxide pneumoperitoneum to a pressure of 12–15 mm Hg. Next, 12-mm umbilical, 5-mm right upper quadrant, 5-mm left lower quadrant, and 15-mm left upper quadrant trocars were placed. A purse-string suture was placed on the anterior wall of the stomach. A gastrotomy was made using ultrasonic shears and the 15-mm trocar was placed into the stomach. The endoscope was then inserted through the 15-mm trocar, and the pneumoperitoneum was decreased to 10 mm Hg. Once the evaluation was complete, the gastrotomy was closed with a running suture or linear stapler. Results Ten patients at our institution have undergone laparoscopic transgastric endoscopy. Five patients had biliary pathologic findings. Four of these patients underwent successful endoscopic retrograde cholangiopancreatography and papillotomy; the procedure in the fifth patient was unsuccessful because stone impaction at the ampulla. Three patients were evaluated for gastrointestinal bleeding. One was diagnosed with a duodenal gastrointestinal stromal tumor, one with a bleeding duodenal ulcer, requiring surgical exploration; and the third had negative endoscopy findings. Two patients evaluated for chronic abdominal pain had negative endoscopy findings. No complications developed. Conclusions Laparoscopic transgastric endoscopy is a safe and minimally invasive approach for the evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergone Roux-en- Y gastric bypass.