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Tailored access to the hepatobiliary system in post-bariatric patients: a tertiary care bariatric center experience

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Abstract

Background

In bariatric surgery patients, pancreaticobiliary access via endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging and the optimal approach for the evaluation and treatment of biliary tree-related pathologies has been debated. Besides laparoscopy-assisted ERCP (LA-ERCP) as standard of care, EUS-directed transgastric ERCP (EDGE) and hepaticogastrostomy (HGS) with placement of a fully covered metal stent have emerged as novel techniques. The objective of this study was to evaluate safety and efficacy of three different endoscopic approaches (LA-ERCP, EDGE, and HGS) in bariatric patients.

Methods

In this retrospective review, consecutive patients with Roux-en-Y gastric bypass (RYGB) and Sleeve Gastrectomy (SG) who underwent from 2013 to 2019 a LA-ERCP, an EDGE, or a HGS at a tertiary care reference center for bariatric surgery were analyzed. Patient demographics, type of procedure and indication, data regarding cannulation and therapeutic intervention of the common bile duct (procedure success), and clinical outcomes were analyzed.

Results

A total of 19 patients were included. Indications for LA-ERCP, EDGE, or HGS were mostly choledocholithiasis (78.9%) and in a few cases papillitis stenosans. Eight patients (57.1%) with LA-ERCP underwent concomitant cholecystectomy. Procedure success was achieved in 100%. Adverse events (AEs) were identified in 15.7% of patients (all ERCP related). All AEs were rated as moderate and there were no serious AEs.

Conclusion

This case series indicates that ERCP via a transgastric approach (LA-ERCP, EDGE, or HGS) is a minimally invasive, effective, and feasible method to access the biliary tree in bariatric patients. These techniques offer an appealing alternative treatment option compared to percutaneous transhepatic cholangiography and drainage- or deep enteroscopy-assisted ERCP. In bariatric patients who earlier had a cholecystectomy, EUS-guided techniques were the preferred treatment options for biliary pathologies.

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References

  1. Shiffman ML, Sugerman HJ, Kellum JH, Brewer WH, Moore EW (1993) Gallstones in patients with morbid obesity Relationship to body weight, weight loss and gallbladder bile cholesterol solubility. Int J Obes Relat Metab Disord 17(3):153–158

    CAS  Google Scholar 

  2. Sugerman HJ, Brewer WH, Shiffman ML, Brolin RE, Fobi MA, Linner JH et al (1995) A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg 169(1):91–96

    Article  CAS  Google Scholar 

  3. Banerjee N, Parepally M, Byrne TK, Pullatt RC, Cote GA, Elmunzer BJ (2017) Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 13(7):1236–1242

    Article  Google Scholar 

  4. Frederiksen NA, Tveskov L, Helgstrand F, Naver L, Floyd A (2017) Treatment of common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg 27(6):1409–1413

    Article  Google Scholar 

  5. Schreiner MA, Chang L, Gluck M, Irani S, Gan SI, Brandabur JJ et al (2012) Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc 75(4):748–756

    Article  Google Scholar 

  6. Ngamruengphong S, Nieto J, Kunda R, Kumbhari V, Chen YI, Bukhari M et al (2017) Endoscopic ultrasound-guided creation of a transgastric fistula for the management of hepatobiliary disease in patients with Roux-en-Y gastric bypass. Endoscopy 49(6):549–552

    Article  Google Scholar 

  7. Kedia P, Sharaiha RZ, Kumta NA, Kahaleh M (2014) Internal EUS-directed transgastric ERCP (EDGE): game over. Gastroenterology 147(3):566–568

    Article  Google Scholar 

  8. Kedia P, Tyberg A, Kumta NA, Gaidhane M, Karia K, Sharaiha RZ et al (2015) EUS-directed transgastric ERCP for Roux-en-Y gastric bypass anatomy: a minimally invasive approach. Gastrointest Endosc 82(3):560–565

    Article  Google Scholar 

  9. Binmoeller KF, Nguyen-Tang T (2011) Endoscopic ultrasound-guided anterograde cholangiopancreatography. J Hepato-Biliary-Pancreat Sci 18(3):319–331

    Article  Google Scholar 

  10. Tyberg A, Nieto J, Salgado S, Weaver K, Kedia P, Sharaiha RZ et al (2017) Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc 50(2):185–190

    Article  Google Scholar 

  11. Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC et al (2010) A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 71(3):446–454

    Article  Google Scholar 

  12. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  Google Scholar 

  13. Abbas AM, Strong AT, Diehl DL, Brauer BC, Lee IH, Burbridge R et al (2018) Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Gastrointest Endosc 87(4):1031–1039

    Article  Google Scholar 

  14. Weilert F, Binmoeller KF, Marson F, Bhat Y, Shah JN (2011) Endoscopic ultrasound-guided anterograde treatment of biliary stones following gastric bypass. Endoscopy 43(12):1105–1108

    Article  CAS  Google Scholar 

  15. Szary NM, Al-Kawas FH (2013) Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them. Gastroenterol Hepatol 9(8):496–504

    Google Scholar 

  16. Maubach J, Gruber M, Nett P, Macpherson AJ, Worni M (2018) EUS-guided hepaticojejunostomy with transjejunal per-oral cholangioscopy and electrohydraulic lithotripsy in a patient with complicated choledocholithiasis after Roux-en-Y gastric bypass. VideoGIE 3(11):351–353

    Article  Google Scholar 

  17. Raithel M, Dormann H, Naegel A, Boxberger F, Hahn EG, Neurath MF et al (2011) Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients. World J Gastroenterol 17(18):2302–2314

    Article  Google Scholar 

  18. Moreels TG, Hubens GJ, Ysebaert DK, de Beeck BO, Pelckmans PA (2009) Diagnostic and therapeutic double-balloon enteroscopy after small bowel Roux-en-Y reconstructive surgery. Digestion 80(3):141–147

    Article  Google Scholar 

  19. Itoi T, Ishii K, Sofuni A, Itokawa F, Tsuchiya T, Kurihara T et al (2011) Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis. Surg Endosc 25(3):713–721

    Article  Google Scholar 

  20. Shah RJ, Smolkin M, Yen R, Ross A, Kozarek RA, Howell DA et al (2013) A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc 77(4):593–600

    Article  Google Scholar 

  21. Hatanaka H, Yano T, Tamada K (2015) Tips and tricks of double-balloon endoscopic retrograde cholangiopancreatography (with video). J Hepato-biliary-pancreatic Sci 22(6):E28–34

    Article  Google Scholar 

  22. Skinner M, Popa D, Neumann H, Wilcox CM, Monkemuller K (2014) ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 46(7):560–572

    Article  Google Scholar 

  23. Greenstein AJ, O'Rourke RW (2011) Abdominal pain after gastric bypass: suspects and solutions. Am J Surg 201(6):819–827

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland

    Dino Kröll, Alexandra Charlotte Müller, Philipp C. Nett, Reiner Wiest, Johannes Maubach, Guido Stirnimann, Daniel Candinas & Yves Michael Borbély

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  1. Dino Kröll
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  2. Alexandra Charlotte Müller
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  3. Philipp C. Nett
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  4. Reiner Wiest
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  5. Johannes Maubach
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  6. Guido Stirnimann
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  7. Daniel Candinas
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  8. Yves Michael Borbély
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Correspondence to Dino Kröll.

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Dino Kröll, Alexandra Charlotte Müller, Philipp C. Nett, MD, Reiner Wiest, Johannes Maubach, Guido Stirnimann, Daniel Candinas, and Yves Michael Borbély have no conflict of interest or financial ties to disclose.

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Kröll, D., Müller, A.C., Nett, P.C. et al. Tailored access to the hepatobiliary system in post-bariatric patients: a tertiary care bariatric center experience. Surg Endosc 34, 5469–5476 (2020). https://doi.org/10.1007/s00464-019-07343-3

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