Laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography for choledocholithiasis after Roux-en-Y gastric bypass: A case report

Colangiopancreatografía endoscópica asistida por laparoscopia para el tratamiento de coledocolitiasis en pacientes con Y de Roux

Introducción. Los pacientes con antecedente de baipás gástrico que presentan coledocolitiasis no pueden ser tratados con la técnica convencional de colangiopancreatografía retrógrada endoscópica. En estos casos, la vía transgástrica abierta o asistida por laparoscopia, se convierte en una excelente alternativa a la exploración abierta de la vía biliar. Métodos. Estudio retrospectivo que incluyó pacientes adultos con coledocolitiasis y antecedente de gastrectomía subtotal o baipás gástrico con Y de Roux, llevados a colangiopancreatografía endoscópica transgástrica laparoasistida, entre enero de 2019 y diciembre de 2021, en la Clínica CES de Medellín, Colombia. Resultados. Se encontraron siete pacientes, todos con antecedente de baipás gástrico para el manejo de la obesidad. La tasa de identificación y canulación de la vía biliar y extracción de cálculos fue del 100 % mediante el abordaje transgástrico laparo-asistido. Conclusión. De acuerdo con varias revisiones sistemáticas, esta técnica es relativamente fácil de implementar y segura, presentando una tasa de complicaciones inferior a 5 %. Se propone una variante de esta técnica.

Clinical observation of laparoscopic cholecystectomy combined with endoscopic retrograde cholangiopancreatography or common bile duct lithotripsy

BACKGROUND

The incidence of common bile duct (CBD) stones accounts for approximately 10%–15% of all CBD diseases. Approximately 8%–20% of these patients also have gallstones with heterogenous signs and symptoms.

AIM

To investigate the clinical effects of laparoscopic cholecystectomy (LC) combined with endoscopic retrograde cholangiopancreatography (ERCP) and LC with CBD excision and stone extraction in one-stage suture (LBEPS) for the treatment of gallbladder and CBD stones.

METHODS

Ninety-four patients with gallbladder and CBD stones were selected from our hospital from January 2018 to June 2021. They were randomly divided into study and control groups with 47 patients each. The study group underwent LC with ERCP, and the control group underwent LC with LBEPS. Surgery, recovery time of gastrointestinal function, complication rates, liver function indexes, and stress response indexes were measured pre- and postoperatively in both the groups.

RESULTS

The durations of treatment and hospital stay were shorter in the study group than in the control group. There was no significant difference between the one-time stone removal rate between the study and control groups. The time to anal evacuation, resumption of oral feeding, time to bowel sound recovery, and time to defecation were shorter in the study group than in the control group. The preoperative serum direct bilirubin (DBIL), total bilirubin (TBIL), and alanine aminotransferase (ALT) levels were insignificantly higher in the study group than that in the control group. A day after surgery, the postoperative serum DBIL, TBIL, and ALT levels were lower than their preoperative levels in both groups, and of the two groups, the levels were lower in the study group. Although the preoperative serum adrenocorticotrophic (ACTH), cortisol (COR), epinephrine (A), and norepinephrine (NE) levels were higher in the study group than that in the control group, these differences were not significant (P > 0.05). The serum ACTH, COR, A, and NE levels in both groups decreased one day after surgery compared to the preoperative levels, but the inter-group difference was statistically insignificant. Similarly, (91.79 ± 10.44) ng/mL, A, and NE levels were lower in the study group than in the control group. The incidence of complications was lower in the study group than in the control group.

CONCLUSION

LC combined with ERCP induces only a mild stress response; this procedure can decrease the risk of complications, improve liver function, and achieve and promote a faster recovery of gastrointestinal functions.

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 combined malignant biliary-duodenal obstruction in Roux-en-Y gastric bypass anatomy with EUS-guided gastrogastrostomy, EUS biliary drainage, and duodenal stent placement

Video 1Demonstration of deploying lumen-apposing metal stents for gastrogastrostomy and choledochoduodenostomy in a patient with Roux-en-Y gastric bypass anatomy, as well as EUS-guided fine needle biopsy for pancreatic mass.