Abstract
Background
Treatment of choledocholithiasis after Roux-en-Y gastric bypass (RYGB) is a therapeutic challenge given the altered anatomy. To overcome this technical difficulty, different modified endoscopic approaches have been described but significant morbidity accompanies these procedures. The aim of the present study is to report our experience with laparoscopic transcystic common bile duct exploration (LTCBDE) as treatment of choledocholithiasis after RYGB.
Methods
This is a retrospective cohort study of 854 consecutive patients with RYGB at a single institution between January 2007 and December 2019. Our study population focused on patients who developed biliary events after RYGB. Demographic data and perioperative parameters were compared between patients who underwent laparoscopic cholecystectomy (LC) after RYGB with (defined as Group A) and without (defined as Group B) LTCBDE.
Results
Fifty-seven (8.93%) patients developed a biliary event after RYGB that led to LC. Of those, 11 (19.2%) presented choledocholithiasis during intraoperative cholangiogram and were simultaneously treated with LTCBDE (Group A). Choledocholithiasis was unsuspected in the preoperative setting in 7 (63.6%) of the 11 patients. The procedure was successful in 90.9% (n = 10). Comparing Group A and B, no statistically significant differences were found regarding age, gender, length of hospital stay, and morbidity (p > 0.05). Mean operative time of Group A was 113.1 min, adding, on average, 35 min to LC (113.1 min vs 77.9 min, p = 0.004).
Conclusions
LTCBDE offers an effective approach for common bile duct stones in patients who underwent RYGB. This procedure did not add significant length of hospital stay nor morbidity to laparoscopic cholecystectomy.
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References
Gloy VL, Briel M, Bhatt DL et al (2013) Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials. BMJ 347:f5934. https://doi.org/10.1136/bmj.f5934
Picot J, Jones J, Colquitt JL et al (2009) The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 13(41):1–190, 215–357, iii–iv. https://doi.org/10.3310/hta13410
Buchwald H, Avidor Y, Braunwald E et al (2004) Bariatric surgery: a systematic review and meta-analysis [published correction appears in JAMA. 2005 Apr 13;293(14):1728]. JAMA 292(14):1724–1737. https://doi.org/10.1001/jama.292.14.1724
Sjöström L (2013) Review of the key results from the Swedish Obese Subjects (SOS) trial—a prospective controlled intervention study of bariatric surgery. J Intern Med 273(3):219–234. https://doi.org/10.1111/joim.12012
Golzarand M, Toolabi K, Farid R (2017) The bariatric surgery and weight losing: a meta-analysis in the long- and very long-term effects of laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy on weight loss in adults. Surg Endosc 31(11):4331–4345. https://doi.org/10.1007/s00464-017-5505-1
Villegas L, Schneider B, Provost D et al (2004) Is routine cholecystectomy required during laparoscopic gastric bypass? Obes Surg 14(1):60–66. https://doi.org/10.1381/096089204772787301
Manes G, Paspatis G, Aabakken L et al (2019) Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 51(5):472–491. https://doi.org/10.1055/a-0862-0346
Czerwonko ME, Pekolj J, Uad P et al (2018) Acute pancreatitis after laparoscopic transcystic common bile duct exploration: an analysis of predisposing factors in 447 patients. World J Surg 42(10):3134–3142. https://doi.org/10.1007/s00268-018-4611-0
Jagtap N, Hs Y, Tandan M et al (2020) Clinical utility of ESGE and ASGE guidelines for prediction of suspected choledocholithiasis in patients undergoing cholecystectomy. Endoscopy. https://doi.org/10.1055/a-1117-3451
Dasari BV, Tan CJ, Gurusamy KS et al (2013) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013(12):CD003327. https://doi.org/10.1002/14651858.CD003327
Clayton ESJ, Connor S, Alexakis N, Leandros E (2006) Metaanalysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg 93(10):1185–1191
Mohammad B, Richard MN, Pandit A, Zuccala K, Brandwein S (2019) Outcomes of laparoscopic-assisted ERCP in gastric bypass patients at a community hospital center. Surg Endosc. https://doi.org/10.1007/s00464-019-07310-y
Skinner M, Popa D, Neumann H, Wilcox CM, Mönkemüller K (2014) ERCP with the overtube-assisted enteroscopy technique: a systematic review. Endoscopy 46(7):560–572. https://doi.org/10.1055/s-0034-1365698
Wang TJ, Ryou M (2018) Evolving techniques for endoscopic retrograde cholangiopancreatography in gastric bypass patients. Curr Opin Gastroenterol 34(6):444–450. https://doi.org/10.1097/MOG.0000000000000474
Ayoub F, Brar TS, Banerjee D et al (2020) Laparoscopy-assisted versus enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in Roux-en-Y gastric bypass: a meta-analysis. Endosc Int Open 8(3):E423–E436. https://doi.org/10.1055/a-1070-9132
Czerwonko ME, Pekolj J, Uad P et al (2019) Laparoscopic transcystic common bile duct exploration in the emergency is as effective and safe as in elective setting. J Gastrointest Surg 23(9):1848–1855. https://doi.org/10.1007/s11605-018-4029-x
Talha A, Abdelbaki T, Farouk A, Hasouna E, Azzam E, Shehata G (2019) Cholelithiasis after bariatric surgery, incidence, and prophylaxis: randomized controlled trial. Surg Endosc. https://doi.org/10.1007/s00464-019-07323-7
Miller K, Hell E, Lang B, Lengauer E (2003) Gallstone formation prophylaxis after gastric restrictive procedures for weight loss: a randomized double-blind placebo-controlled trial. Ann Surg 238(5):697–702. https://doi.org/10.1097/01.sla.0000094305.77843.cf
Altieri MS, Yang J, Nie L, Docimo S, Talamini M, Pryor AD (2018) Incidence of cholecystectomy after bariatric surgery. Surg Obes Relat Dis 14(7):992–996. https://doi.org/10.1016/j.soard.2018.03.028
Mishra T, Lakshmi KK, Peddi KK (2016) Prevalence of cholelithiasis and choledocholithiasis in morbidly obese South Indian patients and the further development of biliary calculus disease after sleeve gastrectomy, gastric bypass and mini gastric bypass. Obes Surg 26(10):2411–2417. https://doi.org/10.1007/s11695-016-2113-4
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. https://doi.org/10.1007/s00464-011-1593-5
Abbas AM, Strong AT, Diehl DL 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. https://doi.org/10.1016/j.gie.2017.10.044
Grimes KL, Maciel VH, Mata W, Arevalo G, Singh K, Arregui ME (2015) Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc 29(7):1753–1759. https://doi.org/10.1007/s00464-014-3901-3
Ali MF, Modayil R, Gurram KC, Brathwaite CEM, Friedel D, Stavropoulos SN (2018) Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc 87(5):1241–1247. https://doi.org/10.1016/j.gie.2017.12.024
Pan L, Chen M, Ji L et al (2018) The safety and efficacy of laparoscopic common bile duct exploration combined with cholecystectomy for the management of cholecysto-choledocholithiasis: an up-to-date meta-analysis. Ann Surg 268(2):247–253. https://doi.org/10.1097/SLA.000000000000273
Pekolj J, Alvarez FA, Palavecino M, Sánchez Clariá R, Mazza O, de Santibañes E (2013) Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg 216(5):894–901. https://doi.org/10.1016/j.jamcollsurg.2013.01.051
Strömberg C, Nilsson M, Leijonmarck CE (2008) Stone clearance and risk factors for failure in laparoscopic transcystic exploration of the common bile duct. Surg Endosc 22(5):1194–1199. https://doi.org/10.1007/s00464-007-9448-9
Hua J, Meng H, Yao L et al (2017) Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution. Surg Endosc 31(9):3581–3589. https://doi.org/10.1007/s00464-016-5388-6
Zhu J, Sun G, Hong L, Li X, Li Y, Xiao W (2018) Laparoscopic common bile duct exploration in patients with previous upper abdominal surgery. Surg Endosc 32(12):4893–4899. https://doi.org/10.1007/s00464-018-6248-3
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Study conception and design: IF, AB, FW, PU, MS, MP, OM. Acquisition of data: IF, AB, PU, MP, RSC, JP, OM. Analysis and interpretation of data: IF, AB, FW, PU, MS, MP, RSC, JP, OM. Drafting of manuscript: IF, AB, FW, PU, MS, MP, OM. Critical revision: AB, FW, PU, MS, RSC, MP, OM.
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Drs Ignacio Fuente, Axel Beskow, Fernando Wright, Pedro Uad, Martín de Santibañes, Martin Palavecino, Rodrigo Sanchez-Claria, Juan Pekolj, and Oscar Mazza have no conflict of interest or financial ties to disclose.
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Fuente, I., Beskow, A., Wright, F. et al. Laparoscopic transcystic common bile duct exploration as treatment for choledocholithiasis after Roux-en-Y gastric bypass. Surg Endosc 35, 6913–6920 (2021). https://doi.org/10.1007/s00464-020-08201-3
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DOI: https://doi.org/10.1007/s00464-020-08201-3