Laparoscopic-Assisted Endoscopic Retrograde Cholangiopancreatography

  • Thadeus L. TrusEmail author
  • B. Fernando Santos


Patients with altered anatomy who require endoscopic retrograde cholangiopancreatography (ERCP) present a challenge to the surgeon and require a specialized approach. In the past, most patients had altered anatomy secondary to duodenal ulcer operations, specifically a Billroth II reconstruction with afferent and efferent limbs. More common in the current era are patients with altered anatomy secondary to bariatric surgery, specifically laparoscopic Roux-en-Y gastric bypass (RYGB). Cholecystectomy in patients with altered anatomy can usually be performed laparoscopically, but access to the duodenum and the major papilla via transoral ERCP may be extremely difficult and frequently impossible. Even if one is able to access the duodenum using a transoral approach, impaired visualization of the papilla and scope instability can reduce the likelihood of deep biliary cannulation and technical success. Given the difficulty and poor success rate of transoral ERCP in RYGB patients, laparoscopic-assisted ERCP has developed as a safe and reliable way to allow ERCP.


Endoscopic retrograde cholangiopancreatography (ERCP) Laparoscopic-assisted ERCP Altered anatomy Billroth II reconstruction Roux-en-Y gastric bypass (RYGB) 

Supplementary material

Video 14.1

Laparoscopic-assisted ERCP through the gastric remnant in a post-RYGB patient (MP4 280089 kb)

Video 14.2

Laparoscopic-assisted ERCP through the biliopancreatic limb in a post-RYGB patient without an intact gastric remnant (MP4 364904 kb)


  1. 1.
    Grover BT, Kothari SN. Biliary issues in the bariatric population. Surg Clin North Am. 2014;94:413–25.CrossRefGoogle Scholar
  2. 2.
    Sugerman HJ, Brewer WH, Shiffman ML, Brolin RE, Fobi MA, Linner JH, et al. 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. 1995;169:91–6.CrossRefGoogle Scholar
  3. 3.
    Ponsky JL, Jones N, Rodriguez JH, Kroh MD, Strong AT. Massive biliary dilation after Roux-en-Y gastric bypass: is it ampullary achalasia? J Am Coll Surg. 2017;224(6):1097–103.CrossRefGoogle Scholar
  4. 4.
    Banerjee N, Parepally M, Byrne TK, Pullatt RC, Coté GA, Elmunzer BJ. Systemic review of transgastric ERCP in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis. 2017;13(7):1236–42.CrossRefGoogle Scholar
  5. 5.
    Choi EK, Chiorean MV, Coté GA, El Hajj II, Ballard D, Fogel EL, et al. ERCP via gastrostomy vs. double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc. 2013;27(8):2894–9.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Chavalitdhamrong D, Wagh M, Lara L, Ben-David K, Draganov P. Prospective evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Am J Gastroenterol. 2014;109:S590–1.Google Scholar
  7. 7.
    Snauwaert C, Laukens P, Dillemans B, Himpens J, De Looze D, Deprez PH, et al. Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography in bariatric Roux-en-Y gastric bypass patients. Endosc Int Open. 2015;3(5):E458–63.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Neto MG, Falcao M, Campos JM, Bandeira Ferrax AA. Laparoscopy-assisted transgastric ERCP and papillotomy in gastric bypass bariatric patients. Initial series of 16 cases. Obes Surg. 2010;20(8):1000.Google Scholar
  9. 9.
    Lin C, Aragon RJ, Carr AD, Ali MR. Direct access ERCP: a novel and reliable surgical technique for patients with Roux-en-Y anatomy. Surg Endosc. 2014;28:422.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryGeisel School of Medicine, Dartmouth-Hitchcock Medical CenterLebanonUSA
  2. 2.Department of SurgeryGeisel School of Medicine, Dartmouth CollegeHanoverUSA
  3. 3.Veterans Affairs Medical Center, White River JunctionHartfordUSA

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