SINGLE STEP TECHNIQUE OF LAPAROSCOPIC TRANSGASTRIC ERCP FOR BILE LEAK AFTER ROUX-EN-Y GASTRIC BYPASS

Abstract

Introduction: ERCP in patients who have undergone Roux-en-Y gastrojejunostomy can be challenging. The procedure is often unsuccessful when the Roux-en-Y limb is 150 cm or greater. ERCP via an existing gastrostomy after gastric bypass has been reported for the treatment of biliary stricture and pancreatitis. We report a novel method of a single step technique of laparoscopic transgastric ERCP for treatment of a post cholecystectomy bile leak after Roux-en-Y gastric bypass. In order to complete the ERCP, a laparoscopic gastrostomy was placed to provide access to the ampulla. History: A 49 year old woman presented with bile leak one week post laparoscopic cholecystectomy. She had a history of gastric bypass for morbid obesity 13 months prior. The length of the Roux-en-Y limb was 150 cm. ERCP was attempted using a pediatric colonoscope advanced through the mouth, however the papilla could not be reached. The patient was brought to the operating room where she underwent a single step technique of laparoscopic gastrostomy placement into the stapled off gastric remnant. The anatomic placement of the gastrostomy necessitated the use of a standard forward viewing endoscope to identify the path to the duodenum. A guide wire was placed through the gastrostomy to the duodenum. A side viewing endoscope was then advanced over the wire. The major papilla was cannulated and cholangiogram identified a bile leak at the cystic duct stump. A 10 French 10 cm stent was placed into the common bile duct for decompression. The gastrostomy was left intact for removal of the stent six weeks later. Results: The patient recovered rapidly, and six weeks later underwent a repeat ERCP through the gastrostomy. The previously placed stent was removed and repeat cholangiogram revealed no evidence of recurrent bile leak. The gastrostomy tube was removed two weeks later. Conclusions: Laparoscopic transgastric ERCP for bile leak can be successfully performed in a single step technique. This method is a reasonable alternative to conventional ERCP in patients with gastric bypass surgery, particularly when the Roux-en-Y limb is very long or when the treatment may require multiple ERCPs for repeat access to the papilla such as stent removal and/or exchange. Successful endoscopic treatment of biliary leak has the potential to avoid complicated biliary reconstructive surgery. We conclude that ERCP via a laparoscopic gastrostomy performed in a single step, is both safe and feasible after Roux-en-Y gastrojejunostomy.