Abstract
Background
The altered anatomy of Roux-en-Y gastric bypass presents a challenge when duodenal access is required for ERCP. One technique, laparoscopic transgastric ERCP, was first described in 2002. Since that time, a total of 77 laparoscopic or percutaneous transgastric ERCPs have been reported. The largest case series includes 26 ERCPs, and no reports specifically address complications. We reviewed our experience with 85 transgastric ERCPs and report the limitations and complications associated with access and ERCP.
Methods
Retrospective review was conducted of gastric bypass patients who underwent transgastric ERCP in our practice from 2004–2014.
Results
Forty-one patients underwent 85 transgastric ERCPs during the study period. Conversion from laparoscopic to open procedure occurred in 4.8 %, and selective cannulation rate was 93 %. Forty-seven percent of cases were repeat ERCPs performed through a gastrostomy tube tract. During 15-month median follow-up, the overall complication rate was 19 %, with 88 % of complications related to access rather than ERCP. Most complications were minor; there were no deaths or cases of severe pancreatitis. Additional intervention, including repair of a posterior stomach laceration or transfusion for bleeding, occurred in 4.7 % of cases. Operative intervention occurred in two cases: repair of a duodenal perforation, and debridement of an abdominal wall abscess. Post-ERCP hyperamylasemia was common but did not result in increased length of stay or significant clinical pancreatitis.
Conclusions
Roux-en-Y gastric bypass eliminates the normal approach to the duodenum for ERCP. Transgastric access has a high rate of successful cannulation but is associated with complications. Conversion to open procedure occurred in 4.8 %, and 16 % developed a complication related to the access site, though the rate of operative intervention was low (2.4 %). Our study is limited by its retrospective design, which may underestimate the complication rate, and by our homogenous patient population (94 % female, 68 % sphincter of Oddi dysfunction).
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References
Richardson JF, Lee JG, Smith BR, Nguyen B, Pham KP, Nguyen NT (2012) Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass: case series and review of the literature. Am Surg 78(10):1182–1186 Epub 2012/10/03
Schapira L, Falkenstein DB, Zimmon DS (1975) Endoscopy and retrograde cholangiography via gastrostomy. Gastrointest Endosc 22(2):103
Baron TH, Vickers SM (1998) Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Gastrointest Endosc 48(6):640–641
Peters M, Papasavas PK, Caushaj PF, Kania RJ, Gagne DJ (2002) Laparoscopic transgastric endoscopic retrograde cholangiopancreatography for benign common bile duct stricture after Roux-en-Y gastric bypass. Surg Endosc 16(7):1106. doi:10.1007/s00464-001-4180-3
Martinez J, Guerrero L, Byers P, Lopez P, Scagnelli T, Azuaje R et al (2006) Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy after Roux-en-Y gastric bypass. Surg Endosc 20(10):1548–1550. doi:10.1007/s00464-005-0267-6
Pimentel R, Mehran A, Szomstein S, Rosenthal R (2004) Laparoscopy-assisted transgastrostomy ERCP after bariatric surgery: case report of a novel approach. Gastrointest Endosc 59(2):325–328
Ceppa FA, Gagne DJ, Papasavas PK, Caushaj PF (2007) Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass. Surg Obes Relat Dis 3(1):21–24. doi:10.1016/j.soard.2006.08.018
Nakao FS, Mendes CJ, Szego T, Ferrari AP (2007) Intraoperative transgastric ERCP after a Roux-en-Y gastric bypass. Endoscopy 39(Suppl 1):E219–E220. doi:10.1055/s-2007-966333
Patel JA, Patel NA, Shinde T, Uchal M, Dhawan MK, Kulkarni A, et al (2008) Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature. Am Surg 74(8):689–693; discussion 693–694
Roberts KE, Panait L, Duffy AJ, Jamidar PA, Bell RL (2008) Laparoscopic-assisted transgastric endoscopy: current indications and future implications. JSLS 12:30–36
Dapri G, Himpens J, Buset M, Vasilikostas G, Ntounda R, Cadiere GB (2009) Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass. Surg Endosc 23(7):1646–1648. doi:10.1007/s00464-009-0417-3
Gutierrez JM, Lederer H, Krook JC, Kinney TP, Freeman ML, Jensen EH (2009) Surgical gastrostomy for pancreatobiliary and duodenal access following Roux en Y gastric bypass. J Gastrointest Surg. 13(12):2170–2175. doi:10.1007/s11605-009-0991-7
Peeters G, Himpens J (2009) A hybrid endo-laparoscopic therapy for common bile duct stenosis of a choledocho-duodenostomy after a Roux-en-Y gastric bypass. Obes Surg 19(6):806–808. doi:10.1007/s11695-009-9829-3
Badaoui A, Malherbe V, Rosiere A, De Ronde T (2010) ERCP by laparoscopic transgastric access and cholecystectomy at the same time in a patient with gastric bypass who was seen with choledocholithiasis. Gastrointest Endosc 71(1):212–214 Epub 2009/08/18
Sebastian JJ, Resa JJ, Pena E, Blas JM, Cena G, Fatas JA (2009) Laparoscopically assisted ERCP in a case of acute cholangitis in a patient with biliopancreatic diversion with distal gastric preservation. Obes Surg 19(2):250–252. doi:10.1007/s11695-008-9683-8
Saleem A, Levy MJ, Petersen BT, Que FG, Baron TH (2012) Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg 16(1):203–208. doi:10.1007/s11605-011-1760-y
Bertin PM, Singh K, Arregui ME (2011) Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc 25(8):2592–2596. doi:10.1007/s00464-011-1593-5
Gottlieb K, Sherman S, Pezzi J, Esber E, Lehman GA (1996) Early recognition of post-ERCP pancreatitis by clinical assessment and serum pancreatic enzymes. Am J Gastroenterol 91(8):1553–1557 Epub 1996/08/01
Monkemuller K, Bellutti M, Neumann H, Malfertheiner P (2008) Therapeutic ERCP with the double-balloon enteroscope in patients with Roux-en-Y anastomosis. Gastrointest Endosc 67(6):992–996. doi:10.1016/j.gie.2007.10.023
Cicek B, Parlak E, Disibeyaz S, Koksal AS, Sahin B (2007) Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy. J Gastroenterol Hepatol 22(8):1210–1213. doi:10.1111/j.1440-1746.2006.04765.x
Malherbe V, Badaoui A, Huybrecht H, De Ronde T, Michel L, Rosiere A (2009) Management of common bile duct stone late after laparoscopic Roux-en-Y gastric bypass for obesity. Acta Chir Belg 109(6):820–823 Epub 2010/02/27
Dapri G, Vaz C, Cadiere GB, Himpens J (2007) A prospective randomized study comparing two different techniques for laparoscopic sleeve gastrectomy. Obes Surg 17(11):1435–1441 Epub 2008/01/26
Falcao M, Campos JM, Galvao Neto M, Ramos A, Secchi T, Alves E et al (2012) Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity. Obes Surg 22(6):872–876. doi:10.1007/s11695-012-0635-y
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Drs. Grimes, Maciel, Mata, Arevalo, Singh, and Arregui have no conflicts of interest or financial ties to disclose.
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Grimes, K.L., Maciel, V.H., Mata, W. et al. Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc 29, 1753–1759 (2015). https://doi.org/10.1007/s00464-014-3901-3
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DOI: https://doi.org/10.1007/s00464-014-3901-3