Efficacy and Safety of 100 Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography Procedures in Patients with Roux-en-Y Gastric Bypass

Current Gallstone Treatment Methods, State of the Art

This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future.

Laparoscopic-Assisted ERCP in Gastric Bypass Patients-No Stones Left Unturned: A Single Center Retrospective Cohort Study

PURPOSE

The long-term need for biliary duct intervention following Roux-en-Y gastric bypass surgery (RYGB) is uncertain. We investigated the rate of laparoscopic assisted retrograde cholangiopancreatography (LAERCP) following RYGB. Also, the pre-LAERCP diagnostic workup together with the true rate of choledocholithiasis in patients with or without prior cholecystectomy was investigated.

MATERIALS AND METHODS

Retrospective cohort study of RYGB and LAERCP performed at the Hospital South West Jutland, University Hospital of Southern Denmark, from 1 January 2013 to 31 May 2022.

RESULTS

One percent of patients (n = 13) with a history of RYGB (n = 1363) underwent LAERCP at our facility during a median follow-up of 60.6 months. The stone extraction rate was 66.7% in patients with in situ gallbladder and 12.5% in patients with prior cholecystectomy. Cannulation of the common bile duct was achieved in 96.7% of cases. Postoperative complications were observed in 22.6% of the cases.

CONCLUSION

Approximately 1% of RYGB patients needed LAERCP during a median follow-up of 5 years. In patients with a history of cholecystectomy, the LAERCP rate of stone extraction was very low (12.5%).

Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size?

OBJECTIVES

The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones.

METHODS

We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105 years, mean 79.1 years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram.

RESULTS

The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5 mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success.

CONCLUSIONS

PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate.

KEY POINTS

• PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5 mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.

Safety and efficacy of LA-ERCP procedure following Roux-en-Y gastric bypass: a systematic review and meta-analysis

INTRODUCTION

Rapid weight loss following Roux-en-Y gastric bypass surgery (RYGB) translates to an increased need for endoscopic retrograde cholangiopancreatography (ERCP) intervention. Laparoscopically Assisted Transgastric ERCP (LA-ERCP) has emerged to address the issue of accessing the excluded stomach. This study aims to evaluate the safety and efficacy of LA-ERCP procedure following RYGB.

METHODS

The Cochrane, EMBASE, SCOPUS, MEDLINE, Daily and Epub databases were searched from inception to May 2022 using the PRISMA guidelines. Eligible studies reported participants older than 18 years who underwent the LA-ERCP procedure, following RYGB, and outcomes of patients.

RESULTS

27 unique studies met the inclusion criteria with 1283 patients undergoing 1303 LA-ERCP procedures. 81.9% of the patients were female and the mean age was 52.18 ± 13.38 years. The rate of concurrent cholecystectomy was 33.6%. 90.9% of procedures were undertaken for a biliary indication. The mean time between RYGB and LA-ERCP was 89.19 months. The most common intervention performed during the LA-ERCP was a sphincterotomy (94.3%). Mean total operative time was 130.48 min. Mean hospital length of stay was 2.697 days. Technical success was 95.3%, while clinical success was 93.8%. 294 complications were recorded with a 20.6% complication rate. The most frequent complications encountered were pancreatitis (6.8%), infection (6.1%), bleeding (3.4%), and perforation (2.5%). Rate of conversion to open laparotomy was 7%.

CONCLUSION

This meta-analysis presents preliminary evidence to suggest the safety and efficacy of LA-ERCP procedure following RYGB. Further investigations are warranted to evaluate the long-term efficacy of this procedure using studies with long-term patient follow-up.

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP.

METHODS

A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs).

RESULTS

Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3-89.4); I2: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4-99.4; I2: 0%) and 99.1% (95%CI: 98.6-99.7; I2: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3-78.0; I2: 86.9%) and 69.1% (95%CI: 65.3-72.9; I2: 91.8%) after EA-ERCP, 98% (95%CI: 96.5-99.6; I2: 0%) and 97.9% (95%CI: 96.3-99.4) after EDGE, and 98.6% (95%CI: 97.9-99.2; I2: 0%) and 98.5% (95%CI: 97.8-99.2; I2: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40-20.8); I2: 87.1%], and EDGE [13.1% (95%CI: 7.50-18.8); I2: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50-6.80); p ≤ 0.04; I2: 64.2%].

CONCLUSIONS

LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events.

Successful treatment through staged laparoscopic transgastric endoscopic retrograde cholangiopancreatography for postoperative bile leakage: A case report

INTRODUCTION

Therapeutic laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography (LA-ERCP) is a safe and effective technique for patient who are unable to receive endoscopic or percutaneous transhepatic treatment. This procedure shows a high overall success rate in managing pancreaticobiliary complications, comparable to that of ERCP.

PATIENT CONCERNS

A 51-year-old man had abdominal pain for 2 days. The patient showed acute calculous cholecystitis and acute cholangitis with distal common bile duct (CBD) stones. We performed laparoscopic cholecystectomy and removed the distal CBD stones through CBD exploration.On the fourth day after the surgery, bile leakage was observed through the surgical drain.

DIAGNOSIS

The patient was diagnosed with postoperative bile leakage based on clinical findings.

INTERVENTIONS

The patient could not receive ERCP or percutaneous transhepatic biliary drainage because he had severe trismus and limb stiffness after suffering from poliomyelitis. So, we performed LA-ERCP, sphincterotomy, and biliary stent insertion. The fully covered self-expanding metal stent was implanted within the percutaneous gastrostomy site around, and 4 weeks later, the stent was removed during re-ERCP.

OUTCOMES

The patient was discharged without any complications. There were no long-term complications noted during the 12-month follow-up.

CONCLUSION/LESSONS

Staged LA-ERCP represents a practical strategy for managing bile leakage and offers a novel solution for patients for whom transoral and transhepatic approaches are unsuitable. As a result, clinicians must know techniques for gaining access to the biliary system, such as LA-ERCP.

Management of choledocholithiasis after Roux-en-Y gastric bypass: a systematic review and pooled proportion meta-analysis

BACKGROUND

Several therapeutic modalities have been proposed for the management of choledocholithiasis (CDL) following Roux-en-Y gastric bypass (RYGB), yet debate exists regarding the optimal management. The purpose of our study was to review the current literature to compare the efficacy of various techniques in the management of CDL post-RYGB.

METHODS

A comprehensive search of multiple databases was conducted. Studies reporting on the management of CDL in patients post-RYGB and including at least 5 patients were eligible for inclusion. The primary outcome was successful stone clearance. Secondary outcomes included procedure duration, length of hospital stay, and adverse events.

RESULTS

Of 3259 identified studies, 53 studies involving 857 patients were included in the final analysis. The mean age was 54.4 years (SD 7.05), 78.8% were female (SD 13.6%), and the average BMI was 30.8 kg/m2 (SD 6.85). Procedures described included laparoscopy-assisted ERCP (LAERCP), balloon-assisted enteroscopy (BAE), ultrasound-directed transgastric ERCP (EDGE), laparoscopic common bile duct exploration (LCBDE), EUS-guided intra-hepatic puncture with antegrade clearance (EGHAC), percutaneous trans-hepatic biliary drainage (PTHBD), and rendezvous guidewire-associated (RGA) ERCP. High rates of successful stone clearance were observed with LAERCP (1.00; 95% CI 0.99-1.00; p = 0.47), EDGE (0.97; 95% CI 0.9-1.00; p = 0.54), IGS ERCP (1.00; 95% CI 0.87-1.00), PTHBD (1.0; 95% CI 0.96-1.00), and LCBDE (0.99; 95% CI 0.93-1.00, p < 0.001). Lower rates of stone clearance were observed with BAE (61.5%; 95%CI 44.3-76.3, p = 0.188) and EGHAC (74.0%; 95% CI 42.9-91.5, p = 0.124). Relative to EDGE, LAERCP had a longer procedure duration (133.1 vs. 67.4 min) but lower complication rates (12.8% vs. 24.3%).

CONCLUSION

LAERCP and EDGE had high rates of success in the management of CDL post-RYGB. LAERCP had fewer complications but was associated with longer procedure times. BAE had lower success rates than both LAERCP and EDGE.