Treatment of biliary disease with transgastric ERCP after Roux-en-Y gastric bypass

Mohammad Farukhi, MD, Benjamin Clapp, MD, Brian Davis, MD, Jennifer George, MD. Texas Tech School of Medicine

Background: Biliopancreatic pathology occurs in the Roux-en-Y gastric bypass (RYGB) population. Anatomical changes after surgery limits endoscopic access to the remnant stomach and thus creates a challenge in performing endoscopic retrograde cholangiopancreatography (ERCP). Laparoscopic assisted-ERCP (L-ERCP)  gains access via the remnant stomach and thus allows assessment and treatment of stones, strictures and other sources of biliary pathology. Although this approach has been described for over a decade, there still remains relatively low experience among surgeons performing it and there is a lack of agreement as regards the optimal method and technique.

Methods: This was a retrospective case series of consecutive patients undergoing L-ERCP between 2014 and 2015. Our objective was to evaluate the treatment and outcome of biliary disease after L-ERCP. We evaluated endoscopic/laparoscopic interventions, conversion rate, postprocedure complications, hospital stay, and procedure time in this study.

All cases were done in a uniform fashion by the same operating surgeon. Keith (straight) needles were used to mobilize the remnant stomach to the anterior abdominal wall. Then a gastrotomy was made with electrocautery large enough to introduce a 15mm trocar. Stay sutures on the stomach secured the stomach to the abdominal wall and an ERCP endoscope was introduced through the port. An intestinal clamp was placed on the biliopancreatic limb. After the ERCP, the gastrotomy was closed using a laparoscopic stapling device.

RESULTS: All seven patients with post-RYGB surgery underwent successful L-ERCP for choledocholithiasis and biliary strictures without conversion to open surgery. Endoscopic cannulation through the papilla with biliary sphincterotomy and a balloon sweep was successfully performed in all cases. The mean duration of the procedure was 72 minutes and the mean postprocedure hospital stay was 1.1 days. These results include one patient who had a cholecystectomy performed during the same operation, one operation with g-tube placement and two procedures which required extensive lysis of adhesions. Two patients were readmitted for abdominal pain of unclear origin. They did not display any laboratory or radiologic abnormalities and they were both discharged after resolution of their symptoms, neither had required any surgical or endoscopic reintervention.

CONCLUSION: L-ERCP using a Keith needle technique for access to the remnant stomach proves to be a safe and effective method to diagnose and treat biliary disease after RYGB. Our preliminary results show successful resolution of choledocholithiasis and biliary strictures without major complications.