Hybrid transgastric rendezvous technique for common bile duct stones after gastric bypass: A combined laparoscopic and endoscopic apprach

Stylianos Tzedakis, MD, Marius Nedelcu, Silvana Perretta, Michel Delvaux, Didier Mutter, Patrick Pessaux. Nouvel Hopital Civil

Introduction: Obtaining access to the biliary tree after a surgically altered anatomy of the upper gastrointestinal (GI) tract is becoming a frequent problem for endoscopists nowadays, especially as bariatric surgery is rapidly growing and the incidence of gallstones due to rapid weight loss is increasing. Several techniques have been put forward to solve this problem based on an endoscopic or a combined laparoscopic and endoscopic approach. These techniques involve single- or double-balloon endoscopy, percutaneous gastrostomy on the excluded stomach, EUS-directed transgastric ERCP, and laparoscopy-assisted transgastric ERCP. However, purely endoscopic techniques still remain challenging, with limited success rates. Laparoscopy-assisted transgastric ERCP (LAERCP) has been described as a safe, highly successful procedure with the unique advantage of allowing diagnosis and possible treatment of internal hernias.

Methods: Here we show the case of a 41 years old woman with a prior history of RYGBP and multiple episodes of pancreatitis secondary to common bile duct (CBD) stones. After failure of double-balloon endoscopic sphicterotomy, a hybrid approach combing laparoscopic transgastric access and endoscopic ERCP and sphicterotomy was attempted.

Results: Under laparoscopic  view a 15mm trocar is introduced into the remnant stomach and an ERCP is performed. Due to difficulties in cannulating the CBD endoscopically a flexible guidewire is introduced laparoscopically through the cystic duct and down through the papilla for an over-the-wire cannulation. Sphicterotomy is completed successfully and multiple stones are extracted. Cholecystectomy is then performed and the gastrotomy is closed by interrupted sutures. Patient’s postoperative course was uneventful with complete resolution of symptoms and cholestasis.

Conclusion: Laparoscopy-assisted ERCP approach is safe, direct and a highly successful option to consider in patients with difficult access to the biliary tree in order to diagnose and manage biliopancreatic pathologies.

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