Brief Report

Laparoscopy-assisted transgastrostomy ERCP after bariatric surgery: case report of a novel approach

Common bile duct lithiasis after Roux-en-Y gastric bypass (RYGB) or upper gastrointestinal stenosis has become a challenging problem nowadays, especially as obesity surgery is increasing. In this study, we assess the feasibility and performance of laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) and describe its technique.

A retrospective review of a prospectively collected database of consecutive patients undergoing a LAERCP between February 2014 and May 2015 was performed at a single institution. Indications were common bile duct lithiasis associated with acute or past episodes of cholangitis and pancreatitis. Endoscopic access to the gastric remnant was obtained laparoscopically.

In total 5 cases were identified. Four of them had undergone a RYGB and one of them presented a benign esophageal peptic stenosis, not allowing peroral gastric access. Biliary cannulation using LAERCP associated with sphincterotomy and stone extraction was successfully achieved in all patients. Mean duration of the entire procedure was 134 minutes (range: 66–200 min). No early major complications were observed and the mean postoperative hospital stay was 4 days (range: 2–5 days).

LAERCP is a safe and successful procedure for the treatment of common bile duct lithiasis when conventional biliary access is not feasible, notably after RYGB. Larger trials still need to be performed to evaluate efficacy, technical success, and complications related to this technique.

ERCP is already the most technically difficult endoscopic procedure, which is made more challenging when the upper GI tract anatomy is surgically altered. A thorough understanding of the variety of surgical reconstructions of the upper GI tract is essential to ensuring technically successful outcomes and minimizing complications. Careful preprocedure planning—for determination of patient's position, endoscope and accessories and for strategizing alternative procedure options—is mandatory. Many operations result in the creation of a gastrojejunostomy in which the afferent or pancreaticobiliary limb is directly accessed from the stomach, such as in Billroth II gastrectomy or pancreaticoduodenectomy. A standard-length endoscope and conventional ERCP accessories may be all that are needed to perform pancreatic or biliary evaluations. Another common form of surgery may involve a Roux-en-Y reconstruction, which tends to require a long-length endoscope, such as a balloon enteroscope, to reach the native papilla or a biliary-enteric anastomosis to perform ERCP. In these situations, endoscopic techniques that are drastically different from and far more difficult than those employing a side-viewing duodenoscope with an elevator may have to be used. Correctly choosing the afferent lumen to advance the endoscope at a surgical anastomosis may significantly reduce the procedure time and improve the chance of technical success.

Biliary disease requiring intervention can be complicated in the postbariatric surgery patient.

A retrospective review was completed to identify patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from September 2001 to September 2014, and those who underwent biliary intervention were identified.

A total of 1527 patients underwent bariatric surgery during the study period. Of the 1,112 patients without prior cholecystectomy, 91 (8%) had biliary symptoms requiring intervention. Ninety patients underwent cholecystectomy, with 86 successfully completed laparoscopically. Six patients required laparoscopy-assisted percutaneous transgastric endoscopic retrograde cholangiopancreatography along with cholecystectomy to clear gallstones from the common bile duct. Three patients who had undergone cholecystectomy before bariatric surgery developed primary common bile duct stones.

Surgery for biliary disease after bariatric surgery can be completed successfully with minimal complications, and percutaneous transgastric endoscopic retrograde cholangiopancreatography has a high success rate of access to and clearance of the biliary tree.

En los pacientes a los que se les ha realizado una cirugía gástrica en Y-de-Roux, la realización de una colangiopancreatografía retrógrada endoscópica (CPRE) es muy dificultosa. Debido al aumento de la prevalencia de la obesidad mórbida y a la realización de cirugías laparoscópicas para su tratamiento, la incidencia de problemas biliares en pacientes con anatomía modificada también es creciente. Presentamos una técnica quirúrgica laparoscópica para acceder a la vía biliar por endoscopio, a través del estómago excluido.

Endoscopic retrograde cholangiopancreatography may be difficult in patients that have undergone Roux-en-Y gastric bypass. Due to the fact that prevalence of morbid obesity is increasing, and laparoscopic procedures for its treatment have increased, the incidence of biliary tract problems in patients of altered anatomy is also growing. We describe a laparoscopic technique to access the biliary tree by endoscope, through the excluded stomach.