Surgical Endoscopy

, Volume 25, Issue 8, pp 2592–2596 | Cite as

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique

  • Peter M. BertinEmail author
  • Kirpal Singh
  • Maurice E. Arregui



Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. The authors describe their technique, indications, and outcomes for this group of patients.


Data were collected by a retrospective chart review of the experience two surgeons had with laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) from July 2004 to October 2008 at a single institution. This review identified 22 cases. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in 18 patients and recurrent pancreatitis in four patients. Adhesions were lysed, and a purse-string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery, and a 12 mm trocar was inserted. It was secured with a purse-string suture. A side-viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. The intended interventions were sphincter of Oddi manometry, sphincterotomy, placement of a pancreatic duct stent, and injection of botulinum toxin if indicated.


Laparoscopic access to the remnant stomach was sufficient for ERCP in 21 cases. One patient required conversion to an open procedure. A total of 12 patients had undergone prior open upper abdominal surgery. One retroperitoneal perforation was noted, with precut sphincterotomy and cannulation of the minor duodenal papilla and no clinical repercussions. Manometry was performed for 18 patients. The pancreatic duct cannulation rate for manometry was 89%, and the rate of bile duct cannulation for manometry was 94%. The manometry studies for 12 patients yielded abnormal results. Eight patients had transient improvement, and three patients had long-term improvement or resolution of symptoms after the index procedure. With additional treatment, two of the transient responders had long-term resolution of symptoms.


The findings demonstrate that gastric bypass patients with biliary pain can be successfully evaluated endoscopically by laparoscopic transgastric ERCP for sphincter of Oddi dysfunction. The rate for technical success and complications does not appear to be significantly greater than for standard ERCP. A few helpful techniques were noted during this experience. Comparison of efficacy with that of a prior study was limited.


Endoscopic retrograde cholangiopancreatography (ERCP) Roux-en-Y gastric bypass Sphincter of Oddi dysfunction Transgastric 



Peter M. Bertin, Kirpal Singh, and Maurice E. Arregui have no conflicts of interest or financial ties to disclose.


  1. 1.
    Lo SK (2008) ERCP in surgically altered anatomy. In: Baron TH, Kozarek R, Carr-Locke D (eds) ERCP. Saunders-Elsevier, Philadelphia, pp 237–258CrossRefGoogle Scholar
  2. 2.
    Martinez J, Guerrero L, Byers P, Lopez P, Scagnelli T, Azuaje R, Dunkin B (2006) Endoscopic retrograde choalngiopancreatography and gastroduodenoscopy after Roux-en-Y gastric bypass. Surg Endosc 20:1548–1550PubMedCrossRefGoogle Scholar
  3. 3.
    Patel JA, Patel NA, Shinde T, Uchal M, Dhawan M, Kulkarni A, Colella J (2008) Endoscopic retrograde cholaniopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature. Am Surg 74:689–694PubMedGoogle Scholar
  4. 4.
    Corazziari E, Shaffer EA, Hogan W, Sherman S, Toouli J (1999) Functional disorders of the biliary tract and pancreas. Gut 45(Suppl2):45–54Google Scholar
  5. 5.
    Hogan W, Sherman S, Pasricha P, Carr-Locke DL (1997) Sphincter of Oddi manometry. Gastrointest Endosc 50:637–641Google Scholar
  6. 6.
    Roberts K, Panait L, Duffy AJ, Jamidar PA, Bell RL (2008) Laparoscopic-assisted transgastric endoscopy: current indications and future implications. JSLS 12:30–36PubMedGoogle Scholar
  7. 7.
    Mönkemüller K, Bellutti M, Neumann H, Malfertheiner P (2008) Therapeutic ERCP with the double-balloon enteroscope in patients with Roux-en-Y anastamosis. Gastrointest Endosc 67:992–995PubMedCrossRefGoogle Scholar
  8. 8.
    Emmett DS, Mallat D (2007) Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series. Gastrointest Endosc 66:1038–1041PubMedCrossRefGoogle Scholar
  9. 9.
    Sato H, Yamamoto H, Tamada K, Kita H, Wada S, Sunada K, Tano S, Hayashi Y, Sato Y, Yano T, Hanatuka K, Ajibe H, Hachimori H, Takamatsu T, Ito K, Shinozaki S, Iwamoto M, Miyata T, Kuno A, Tomiyama T, Ido K, Sugano K (2005) Application of double-balloon endoscopy for afferent limb lesions of Roux-en-Y surgical anastamoses. Gastrointest Endosc 61:AB238CrossRefGoogle Scholar
  10. 10.
    Fogel EL, Sherman S (2006) Sphincter of Oddi dysfunction. In: Cotton P, Leung J (eds) Advanced digestive endoscopy: ERCP. Blackwell, Malden, MA, pp 165–198Google Scholar
  11. 11.
    Wehrmann T, Wiemer K, Lembcke B, Caspary WF, Juno M (1996) Do patients with sphincter of Oddi dysfunction benefit from endoscopic sphincterotomy? A 5 year prospective trial. Eur J Gastroenterol Hepatol 8:245–249CrossRefGoogle Scholar
  12. 12.
    Choudhry U, Ruffolo T, Jamidar P, Hawes R, Lehman G (1993) Sphincter of Oddi dysfunction in patients with intact gallbladder: therapeutic response to endoscopic sphincterotomy. Gastrointest Endosc 39:492–495PubMedCrossRefGoogle Scholar
  13. 13.
    Botoman VA, Kozarek RA, Novell LA, Patterson DJ, Ball TJ, Wechter DG, Neal LA (1994) Long-term outcome after endoscopic sphincterotomy in patients with biliary colic and suspected sphincter of Oddi dysfunction. Gastrointest Endosc 40:165–170PubMedCrossRefGoogle Scholar
  14. 14.
    Bozkurt T, Orth KH, Butsch B, Lux G (1996) Long-term clinical outcome of postcholecystectomy patients with biliary-type pain results of manometry, noninvasive techniques, and endoscopic sphincterotomy. Eur J Gastroenterol Hepatol 8:245–249PubMedCrossRefGoogle Scholar
  15. 15.
    Sherman S, Lehman GA, Jamidar P, Hawes RH, Silverman W, Madura J (1994) Efficacy of endoscopic sphincterotomy and surgical sphincterotomy for sphincter of Oddi dysfunction (SOD): randomized controlled study. Gastrointest Endosc 40:A125CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Peter M. Bertin
    • 1
    Email author
  • Kirpal Singh
    • 2
  • Maurice E. Arregui
    • 2
  1. 1.General Surgery, Department of SurgeryWestmoreland HospitalGreensburgUSA
  2. 2.General Surgery, Department of SurgerySt. Vincent HospitalIndianapolisUSA

Personalised recommendations