Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography for choledocholithiasis after Roux-en-Y gastric bypass: A case report.

Adrian A. Baca-Arzaga,Eduardo Flores-Villalba,Mauricio Gonzalez-Urquijo,Mario Rodarte-Shade

doi:10.1016/j.amsu.2019.06.008

Abstract

BackgroundExclusion of the stomach after Roux-en-Y gastric bypass (RYGB) makes access to the biliary tree very challenging for the surgeon or the endoscopist. Different techniques have been described to overcome this downside, including laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP), which is an outstanding method to access the remnant stomach in order to reach the duodenal papilla. The use of this technique is associated with a high success rate.Presentation of caseHere we present the case of a 57-year-old patient with altered RYGB anatomy. The patient underwent laparoscopic cholecystectomy. Intraoperative cholangiography revealed the presence of a stone in the common bile duct. A laparoscopy-assisted transgastric ERCP was performed successfully. During the procedure, the duodenoscope was introduced through a gastrostomy, obviating the need for an intragastric trocar. The patient evolved favorably and was discharged on second postoperative day without any complications.DiscussionTransgastric laparoscopy-assisted ERCP represents an effective approach for the management of biliary complications after RYGB, even if there is a long interval between the two interventions, as occurred in the present case. Other methods described for accessing the biliary tree in patients with altered RYGB anatomy are double-balloon ERCP and endoscopic ultrasound-directed transgastric ERCP. We elected to perform the laparoscopy-assisted approach because choledocholithiasis was diagnosed transoperatively, thus, avoiding the need for secondary procedures or interventions.ConclusionTransgastric laparoscopy-assisted ERCP is a feasible procedure with low complication rates and is used in treating patients with altered RYGB anatomy who present with biliary tract disorders. The use of transgastric laparoscopy-assisted ERCP allows endoscopic treatment and cholecystectomy to be performed in a single setting.

Highlights

Among all bariatric surgical procedures, Roux-en-Y gastric bypass (RYGB) is considered the “gold standard” for treating the well-known obesity pandemic
We present the case of a 57-year-old male with RYGB-altered anatomy who presented with choledocholithiasis and was subsequently treated successfully with LA-endoscopic retrograde cholangiopancreatography (ERCP) at an academic teaching institution
This led to the development of a new technique that revolutionized the management of biliary stones in patients with RYGB, known as transgastric laparoscopy-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP)

Summary

Introduction

Among all bariatric surgical procedures, Roux-en-Y gastric bypass (RYGB) is considered the “gold standard” for treating the well-known obesity pandemic. The use of this procedure has increased in the last two decades, causing an exponential increase in the prevalence of RYGB anatomy and the frequency with which operating surgeons encounter pathologies that require treatment through the native stomach, such as pancreatobiliary diseases. A 3-cm gastrostomy was created with monopolar electrocautery, and a side-viewing endoscope (Olympus TJF 160 VR or TJF 145) was inserted through the gastric incision, while lifting the suture up against the abdominal wall, to create traction on the stomach, without suturing it to the peritoneum (Fig. 1). At the 12-month follow-up examination, the patient was doing well, with no biliary symptoms; he was satisfied with the treatment he received

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Conclusion

Ethical approval