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Common bile duct post-RYGB

LAERCP is an option for common bile duct post-RYGB

In this retrospective review, the researchers discuss their technique and experience with a combined endoscopic-surgical procedure for management of biliary obstruction in patients post-RYGB

Roux-en-Y gastric bypass (RYGB) patients who may be at a higher risk of post-procedure primary common bile duct (CBD) stone formation can undergo laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP), where transoral access to the biliary tree is not possible, according to researchers from Wake Forest Baptist Medical Center, Winston-Salem, NC.

The paper, ‘Laparoscopic-Assisted Transgastric ERCP: A Single-Institution Experience’, published in the Journal of Obesity, states that LAERCP is a ‘reliable option’ for CBD clearance, as the technique is technically simple and associated with low complication rate, making it appealing to surgeons not trained in advanced laparoscopy.

It is known that RYGB results in changes to the gastrointestinal anatomy so that transoral endoscopic retrograde cholangiopancreatography (ERCP) is not routinely feasible. Bariatric surgery patients are predisposed to cholelithiasis, so an alternative to ERCP is required. In this retrospective review, the researchers discuss their technique and experience with a combined endoscopic-surgical procedure for management of biliary obstruction in patients post-RYGB.

They reviewed 16 cases where the indications for ERCP were choledocholithiasis, cholangitis, and radiographic or clinical evidence of common bile duct (CBD) obstruction – and information was gathered on demographics, laboratory and physiologic data, surgical history, operative and endoscopic reports, hospital length of stay, post-procedure outcomes and follow-up.

Operative technique

The authors write that if recent cholecystectomy had occurred, an open technique was employed to place a periumbilical port through a previous port site. However, if the abdomen had not been recently accessed, they entered with a 5mm optical trocar in either the right or left upper quadrant just below the costal margin with the side chosen at the surgeon’s discretion. A 12 mm port was then placed in the right upper quadrant for passage of the stapler, and it was used if simultaneous cholecystectomy was to be done.

Two additional 5mm ports were placed on either side of the 12mm port in an arc surrounding the right costal margin. In cases that included cholecystectomy, additional 5mm ports were placed as per the standard technique. If the patient had a gallbladder present, it was dissected, a cholangiogram was performed, and it was removed via a standard technique. Cholangiogram was performed with intraoperative consult to GI in those patients with RYGB anatomy undergoing cholecystectomy for gallbladder pathology and uncertain preoperative assessment of the common duct. Cholangiograms were not performed in those patients who had previous cholecystectomy as preoperative radiographic assessment was adequate to establish choledocholithasis and need for ERCP.

The bypassed stomach was identified and adhesions were lysed to mobilise the greater curve up to the abdominal wall. An incision was made in the left upper quadrant to accommodate a 15mm port. Two 2-0 PDS or Prolene sutures were placed through the anterior wall of the stomach on either side of the proposed gastrostomy site. A 15mm port was placed through the abdominal wall and guided through the gastrostomy as stomach was brought to the abdominal wall with the use of the stay sutures (Figure 1). The sutures were then clamped tight to hold the stomach against the abdominal wall. The 15mm port was then re-draped widely for the endoscopy team to proceed with nonsterile ERCP.

Figure 1: (a) Intraoperative photographs of gastropexy technique (b) Transabdominal dilation for introduction of 15mm laparoscopic port for endoscope

After the ERCP was completed, the 15mm port was removed, and the gastrotomy was closed with the use of an endoscopic gastrointestinal stapler using a 3.5mm staple load. If the patient required repeat endoscopic access of the stomach or biliary tract, the gastrotomy was converted into a Stamm gastrostomy. The patient was either sent home from the postoperative recovery unit or admitted for observation.

Outcomes

The researchers report that all patients were intraoperatively confirmed to have standard RYGB anatomy. Eleven of sixteen patients (69%) had undergone cholecystectomy before LAERCP, seven of the eleven (43%) had cholecystectomy performed greater than two years prior to presentation, with a range of 2–17 years. Four of eleven patients with prior cholecystectomy had cholecystectomy at referring institution, immediately prior to transfer or referral, where intraoperative cholangiogram revealed a filling defect in the CBD. The remaining five patients (31%) underwent simultaneous cholecystectomy with LAERCP at our institution. Table 1displays our patient’s demographic and descriptive data.

The longest time from referral to intervention was seven weeks from the diagnosis of choledocholithiasis. Three patients had LAERCP within 48 hours of direct transfer. Four asymptomatic patients were scheduled electively. Three patients underwent an attempt at transoral ERCP by gastroenterologists at referring institutions prior to referral. The average time between cholecystectomy and LAERCP was nine years (range 0–15 years). Four patients underwent outpatient procedures, defined as hospital stay less than 24 hours. The overall average length of stay was 3.7 days. All patients were initially sent to the floor. One patient who developed post-ERCP pancreatitis required subsequent admission to the intensive care unit. Table 2 summarizes our perioperative data.

ERCP with sphincterotomy and cannulation of the CBD was successful in 15 of 16 patients (94%). In all fifteen LAERCP procedures, cholangiogram findings were consistent with choledocholithiasis and balloon-sweep clearance of the duct was successful. In the five cases of simultaneous cholecystectomy, intraoperative cholangiograms via the gallbladder were performed, and all revealed filling defects. All patients underwent successful CBD clearance and there were no mortalities at 30 days.

The researchers noted that 43% of patients presented two or more years after initial cholecystectomy, suggesting that CBD obstruction can occur many years after both cholecystectomy and gastric bypass. The findings indicate that RYGB may predispose patients to primary CBD stone formation and the authors call for more investigations into the causes and preventive measures based on these results.

“The patient population that will require LAERCP is small, but it will increase as RYGB is employed as a treatment for the epidemic of obesity in this country,” the authors conclude. “Primary common bile duct stone formation may be higher than in the general population, as 43% of our patients were two or more years from cholecystectomy at presentation. It is possible that RYGB anatomy and physiology create a predisposition for primary common duct stones. This finding is not well described and needs further research.”

To access this paper, please click here

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