Noble G Jones, MS, Andrew T Strong, MD, John H Rodriguez, Matthew Kroh, Jeffrey L Ponsky, MD. Section of Surgical Endoscopy, Dept. of General Surgery, Cleveland Clinic
Background: Symptomatic biliary dilation commonly follows an obstructive process. However, in the absence of an obvious structural lesion, a functional etiology may be sought. Biliary dilation has been described in patients following either Roux-en-Y gastric bypass (RYGB) or cholecystectomy, but not in patients with a history of both RYGB and cholecystectomy presenting with biliary symptoms and a finding of significant biliary dilation of 10mm or greater in the absence of structural lesions or other obvious etiologies. In this case series, patients presenting with this constellation of symptoms and findings underwent laparoscopic assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) for evaluation and treatment.
Methods: All patients undergoing transgastric ERCP were retrospectively identified from an institutional database. Patients were included if they had no tumor, gallstones, or stricture identified contributing to biliary obstruction.
Results: We identified 13 patients. All patients were female with an average age of 53.8 years (range 38 – 66) and a BMI of 32.3 kg/m2 (range 17.7 – 43.2) at the time of transgastric ERCP. Additionally, all patients had undergone prior RYGB and cholecystectomy. On presentation, 10 patients (76.9%) had post prandial or constant right upper quadrant pain, 8 (61.5%) had abnormal liver enzymes, 8 (61.5%) had nausea and/or vomiting, 4 (30.8%) had at least one prior episode of acute pancreatitis, and 1 (7.7%) had clinical jaundice or increased bilirubin. Preoperative imaging revealed a mean bile duct diameter of 16mm (range 10 – 25 mm). In each case, the papilla appeared normal on endoscopic assessment, and cholangiogram did not reveal choledocholithiasis or strictures within the biliary system. A biliary sphincterotomy was performed on each patient without intraoperative complications. At initial post-operative evaluation, 8 (61.5%) patients had significant symptom improvement.
Conclusions: In this small cohort of post-gastric bypass patients undergoing sphincterotomy for symptomatic significant non-obstructive biliary dilation, an improvement of symptoms was seen in the early postoperative period. This could represent a disease pattern unique to the post gastric bypass population and may reflect vagal nerve injury during that operation. Further investigation is warranted to unearth the etiology of this condition and elucidate the pathophysiology of tonic contraction of the ampulla: ampullary achalasia.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80186
Program Number: P118
Presentation Session: Poster (Non CME)
Presentation Type: Poster
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