S Ayloo, MD FACS, M Masrur, MD, F Gheza, MD, M El Zaeedi, MD, P C Giulianotti, MD FACS. Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA.
Introduction
Having access to biliary structures in sclerosing cholangitis is essential. Surgical reconstructions such as roux-en-y or esophageal-gastric strictures can pose a challenge for procedures such as ERCP to perform cholangiography and stents positioning and exchanges.
Methods
60 years-old woman with a BMI of 35, who underwent ‘gastric stapling’ procedure for weight loss in 1982 presented with schlerosing cholangitis. In 2007 a laparoscopic cholecystectomy converted to open was performed. Since the same year, a diffuse intrahepatic duct irregularities with strongly positive IgG 4 levels consistent with autoimmune cholangiopathy was diagnosed.
She underwent percutaneous biliary drainage requiring constant changes routinely for 3 years every two months. A gastric stricture related to a silastic band was impeding the passage of upper endoscope to perform ERCP. An upper GI performed showed similar to vertical banded gastroplasty with a silastic ring. Our plan was to remove the band and eventually perform a dilatation of the stomach or a gastroplasty.
Results
The procedure started with the extensive lysis of all the adhesions. The silastic ring was circumferential delineated and excised. An attempt was performed to pass the endoscope, but meeting resistance at the site where the silastic ring was we were obligated to perform a gastroplasty.
This was performed by vertical making a gastrotomy, then closing it horizontally to enlarge the lumen. Subsequent to the gastroplasty, an endoscopy was performed, showing an easy passage of the instrument toward the duodenum. The operative time was 165 minutes and estimated blood less than 50 cc. There was no intraoperative complication and the patient was discharged on post operative day 6.
Conclusions
External biliary drainage is the only option in the treatment of intra-hepatic biliary strictures where the access to duodenum is lost because of previous procedures. This video showcases approaching this challenge in minimally invasive technique and resolving the trauma to the patient for constant external drainage exchanges and morbidity of a laparotomy.
Session Number: VidTV3 – Video Channel Rotation Day 3
Program Number: V139