Transgastric Endoscopic Retrograde Cholangiopancreatography: A Case of Reverse Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Abstract

Purpose: Patients who have undergone a Roux-en-Y gastric bypass (RYGB) are at increased risk for gallstone disease. Endoscopy proves to be difficult in these patients due to an altered tortuous anatomy. We will describe an alternative method to access the biliary tree in a bypassed stomach using a transgastric approach with a laparoscopic port and an ERCP endoscope. This method is contrasted to NOTES in that a natural orifice is bypassed. We would like to present two cases of a “reverse NOTES.” Methods: Two female patients, status post gastric bypass with cholecystectomy both present with abdominal pain and also with an increase in liver enzymes. MRCP of both patients revealed a gallstone in the common bile duct. In collaboration with the patients' surgeons, we decided on an ERCP using a laparoscopic transgastric approach. A trocar was inserted into an incision made in the antrum of the stomach. An ERCP scope was passed through the trocar and into the stomach to the duodenum where the major papilla was visualized. The biliary tract was dilated and after a sphincterotomy, the stones were cleared. Both patients tolerated the procedure without complication. Results: Cholelithiasis commonly occurs after RYGB which can advance to choledocholithiasis or gallstone pancreatitis. Patients who have undergone RYGB have a greater than thirty percent of developing gallstones. The reported prevalence of gallstones at six months after gastric bypass is 22 percent. Due to the increased risk of gallstone formation, an incidental cholecystectomy is recommended at the time of surgery. Conclusion: Endoscopic Retrograde Cholangiopancreatography (ERCP) for common bile duct obstruction proves to be technically difficult in patients after a RYGB secondary to the tortuosity of the gastric segment and duodenum. Traditionally, a percutaneous transhepatic access to the common bile duct has been used to manage choledocholithiasis and duct strictures after a gastric bypass. However, using a laparoscopic transgastric approach is an effective and safe method to access the biliary tree in this patient population. This method is contrasted to Natural Orifice Transluminal Endoscopic Surgery (NOTES) in that it effectively bypasses a natural orifice which can modify future ERCP procedures.