Management of Injury to the Common Bile Duct in a Patient with Roux-en-Y Gastric Bypass

Abstract

Introduction. Most surgeons prefer Roux-en-Y hepaticojejunostomy (RYHJ) for biliary reconstruction following a common bile duct (CBD) injury. However, in patients with a Roux-en-Y gastric bypass (RYGB) a RYHJ may be technically challenging and can interfere with bowel physiology induced by RYGB. The use of a hepaticoduodenostomy (HD) resolves both these issues. Presentation of Case. We present a case of CBD injury during laparoscopic cholecystectomy one year after laparoscopic RYGB for morbid obesity. Due to adhesions and previous surgery with RYGB, we did not want to interfere with the RYGB physiology by anastomosing the CBD to the jejunum or ileum. Succeeding a full Kocher's maneuver we performed biliary reconstruction by a tension-free end-to-side HD. The postoperative recovery was uneventful and the patient was discharged after eight days. At four-month follow-up, the patient had stable weight and normal laboratory test results. MRCP demonstrated normal intra- and extrahepatic bile ducts with status after HD. Discussion. We propose that HD should be considered in treatment of CBD injury in post-RYGB patients as it may reduce the risk of interfering with the post-RYGB physiology.

Laparoscopic choledochoduodenal anastomosis after bile duct injury in a patient with previous laparoscopic gastric bypass

“…There was a case report in a patient with similar features whose bypass was performed by open approach. 5…”

“…However, laparoscopic cholecystectomy in this group of patients may result challenging due to the modified anatomy, postoperative adhesions and, frequently, the presence of a previous Roux-en-Y reconstruction. 5 We documented the successful case of a patient with story of non-supplemented laparoscopic gastric bypass, with subsequent injury of bile duct during a cholecystectomy and its repair. All these interventions were performed by minimally invasive surgery and a laparoscopic choledochoduodenal anastomosis was practiced.…”

Hepaticojejunostomy for the management of sump syndrome arising from choledochoduodenostomy in a patient who underwent bariatric Roux-en-Y gastric bypass: A case report

“…The use of choledochoduodenostomy versus hepaticojejunostomy for recurrent CBD stones has been studied. Yaqub et al reported the case of a successful hepaticoduodenostomy (anastomosis between common hepatic duct above the cystic duct junction and the duodenum) following CBD injury in a patient with a history of RYGB [6] . Nonetheless, publications as early as the 1960s have suggested that for benign diseases choledochoduodenostomy should be considered only if there is no other alternative [7] , and a 1975 study published by Stefanini et al reported that over 20% of choledochoduodenostomies ultimately required conversion to formal hepaticojejunostomy [8] .…”