Management of Choledocholithiasis after Roux En Y Gastric Bypass at Tertiary Care Center

Laura E Grimmer, MD, Shaina Eckhouse, MD, Arghavan Salles, PhD, MD, Michael Awad, J. Christopher Eagon, MD, Michael L Brunt, MD. Washington University

Introduction: Numerous options exist for managing choledocholithiasis in patient with prior Roux-en-y gastric bypass (RYGB), including percutaneous, endoscopic, laparoscopic and open approaches. While many studies describe the results of a single preferred management strategy, no study to date has described how the combination of these methods are being used in clinical practice or examined their relative effectiveness.

Methods: We performed a retrospective chart review of patients admitted to our tertiary care center with prior RYGB and diagnosis of choledocholithiasis from 2005-2016. Our primary end point was the final procedure used to successfully clear common bile duct stones. Secondarily, we looked at the total number of procedures required for clearance.

Results: Twenty seven patients with prior RYGB and choledocholithiasis were identified. At time of choledocholithiasis our patients were on average 51 years old, had an average BMI of 29.8, and had undergone RYGB 8.2 years previously. All 27 patients successfully cleared their common bile duct stones, and are classified in Figure 1 by the final, successful procedure resulting in clearance. Nineteen patients underwent laparoscopic cholecystectomy (LC) with intraoperative cholangiogram (IOC) while 8 had undergone prior cholecystectomy. In the 19 patients undergoing LC with IOC, 12 showed filling defect and 7 did not (presumed passed stone). Three patients had initial LC with positive IOC at a community hospital, and subsequently transferred to tertiary center for definitive management. After transfer, one underwent percutaneous transhepatic cholangiogram (PTC), one ERCP via laparoscopic gastrostomy tube and one ERCP per oral for duct clearance. In the remaining 9 patients with positive IOC, laparoscopic common bile duct exploration (LCBDE) was successful using a variety of techniques: basket/balloon transcystic extraction (n=2), pushing stone forward with choledochoscope (n=3), both (n=3) and laparoscopic choledochotomy with direct stone extraction (n=1). In the 8 patients who presented with choledocholithiasis despite prior cholecystectomy, their ducts were cleared using ERCP via laparoscopic gastrostomy tube (n=3), ERCP per oral (n=2), PTC (n=1) and spontaneous resolution (n=2). Altogether, patients required 1.7 procedures on average for successful duct clearance; however every patient undergoing LCBDE needed only 1 procedure, while the remaining patients required 2.04 procedures on average (p < 0.05).

Conclusion: Management of choledocholithiasis in patients with prior RYGB may require a variety of treatment strategies. LCBDE was the most commonly utilized strategy in patients who required concomitant cholecystectomy, and resulted in the fewest invasive procedures overall. In patients with prior cholecystectomy, ERCP via gastrostomy tube was the most common strategy.