Jennifer L Salluzzo, MD1, Stephanie G Wood, MD2, Kurt E Roberts, MD1, Geoffrey S Nadzam, MD1, Matthew O Hubbard, MD1, Saber Ghiassi, MD1, Andrew J Duffy, MD1. 1Yale University School of Medicine, 2Yale-New Haven Hospital
Patients with common bile duct (CBD) stones who have undergone laparoscopic Roux-en-y gastric bypass for morbid obesity pose a challenge for physicians. Traditional ERCP is not possible for retrieval of stones and/or sphincterotomy as the CBD is no longer accessible via EGD. Other potential treatment options include lap-assisted trans-gastric ERCP through the gastric remnant and percutaneous transhepatic cholangiography (PTC) with biliary drainage. These procedures may not be successful in a single attempt and patients are still at risk for CBD obstruction again in the future.
We present a case of a 74 year old female with a history of end stage renal disease on hemodialysis that had a laparoscopic Roux-en-y gastric bypass in 2005 and laparoscopic cholecystectomy in 2010. She presented after her second episode of cholangitis and was found to have multiple CBD stones on MRCP. These were presumed to be primary CBD stones given the time since her cholecystectomy, and therefore, future stone formation was a concern. The consulting gastroenterologists felt she would also require multiple attempts at ERCP to clear her duct with the number of stones present. This would mean several trips to the operating room for lap assisted ERCP or placement of a gastrostomy tube through the remnant for repeat access. She had an extensive medical history and was on several medications and was not an ideal candidate for multiple invasive interventions. A laparoscopic CBD exploration with bypass of the distal CBD would address these concerns and minimize the number of invasive procedures for this patient.
We reviewed the MRI/MRCP and the patient had optimal anatomy for a laparoscopic choledochoduodenostomy. She had a dilated CBD to 1.5cm that abutted the first portion of the duodenum. She was optimized medically and taken to the OR for laparoscopic CBD exploration and choledochoscopy, with removal of several cholesterol-type stones until the duct was clear. This was followed by a single layer anastomosis between the anterior walls of the CBD and duodenum with interrupted non-absorbable suture. A drain was left anterior to the anastomosis. The patient did well post-operatively without complication.
Laparoscopic choledochoduodenostomy is a safe and effective way to provide permanent biliary drainage in the setting of CBD obstruction from stones. It should be considered in gastric bypass patients with CBD stones that are unlikely to be cleared in a single attempt via trans-gastric ERCP or PTC.