INTRODUCION: Rapid weight loss following bariatric surgery can result in cholelithiasis and related complications, including choledocholithiasis. Furthermore, a Roux-en-Y gastric bypass can complicate the management of choledocholithiasis. CASE HISTORY: Here, we present the case of a 72 year-old woman with a history of morbid obesity who underwent a Roux-en-Y gastric bypass and a cholecystectomy for cholelithiasis. She subsequently developed recurrent choledocholithiasis complicated by cholangitis, which was managed conservatively with the use of percutaneous transhepatic cholangiocatheter (PTC). She developed a biliary stricture secondary to false passage of a PTC and went on to suffer further episodes of cholangitis. After over a year and a half of further conservative management, she was offered a laparoscopic hepaticoduodenostomy.
OPERATIVE COURSE: After placing trocars, dense omental adhesions were dissected from the undersurface of the liver. A liver retractor was then placed. The bile duct was then dissected circumferentially. Next, a ductotomy was made approximately 1 cm proximal to the insertion of the bile duct into the pancreatic head. The PTC catheter was grasped and pulled from the duct. The catheter was then cut so that it would retract back into the duct away from the intended site of anastomosis. A white load of the Endo GIA stapling device was used to divide the duct distal to the ductotomy. Next, an enterotomy was then created on the cephalad antimesenteric border of the duodenum. Using a 4-0 PDS suture and diamond dust coated graspers, we performed a running hepaticoduodenostomy, starting on the duct side to allow forehand suturing. The right upper quadrant was irrigated and hemostasis was assured. The 12 mm trocar site and skin incisions were then closed.
RESULTS: A postoperative cholangiogram revealed free passage of contrast into the duodenum. The patient did well and was discharged home on the third postoperative day.
CONCLUSIONS: Laparoscopic hepaticoduodenostomy can serve as a safe and effective management option for patients with distal biliary strictures.
Session: Podium Video Presentation
Program Number: V031