3163 Laparoscopic Transgastric ERCP for Choledocholithiasis After Roux-en-Y Gastric Bypass: A Different Approach to ERCP

Abstract

INTRODUCTION: With bariatric procedures becoming more prevalent, performing an ERCP becomes a challenge with patients who have had bariatric surgeries. CASE DESCRIPTION/METHODS: A 60 year old male with a past medical history of hypertension, diabetes mellitus type 2, and Roux-en-Y gastric bypass surgery developed abdominal pain 3 days prior to admission and was admitted for a laparoscopic cholecystectomy. Pre-operative MRCP did not show any significant common bile duct obstruction (a small non-obstructing stone was noted). Intraoperatively, the stone was found to be obstructing the common bile duct after a cholangiogram was performed. A laparoscopic trans-gastric ERCP was scheduled. The ERCP was scheduled for the next day. After a laparoscopic gastrostomy, the ERCP scope was advanced through the gastrostomy and the stone was removed with standard biliary sphincterotomy and balloon extraction without complications. The gastrostomy site was closed, and the procedure finished without complications. The patient was discharged in good condition 2 days after the procedure. DISCUSSION: An ERCP in a Roux-en-Y gastric bypass patient requires careful planning with surgery. Nonetheless, the time of the procedure is shortened considerably compared to the older double-balloon approach and shorter anesthesia overall is associated with better outcomes for the patient. One surgical approach to these patients is a transgastric approach through gastrostomy (either laparoscopic or open surgical approach). The open approach is achieved by creating an opening in the abdominal wall, and attaching the gastric wall to the opening, then opening it for the ERCP scope to be advanced through. In this particular case, a laparoscopic gastrostomy was performed in the distal area of the stomach, and cannulated with a 15 mm cannula through an umbilical port. An 11 mm ERCP scope was then inserted through the trocar directly into the stomach, and advanced to the pylorus where the gastroenterologist was able to cannulate the common bile duct. A stent was not placed in this particular case, as it would require repeat surgery to remove it. The gastrostomy was then closed by a mini laparotomy. Alternative approaches to GI procedures will become more common with the growing prevalence of bariatric procedures.