Massive Biliary Dilation after Roux-en-Y Gastric Bypass: Is it Ampullary Achalasia?

Gallstones after bariatric surgery: mechanisms and prophylaxis

Gallstones represent a common yet often underappreciated complication following bariatric surgery, with reported incidence rates ranging widely from 10.4% to 52.8% within the first postoperative year. Multiple factors contribute to gallstone formation in this setting, including intraoperative injury to the hepatic branch of the vagus nerve, alterations in bile composition, reduced food intake, shifts in gastrointestinal hormone levels, and dysbiosis of the gut microbiota. Notably, the risk of cholelithiasis varies by surgical procedure, with sleeve gastrectomy (SG) generally associated with a lower incidence compared to Roux-en-Y gastric bypass (RYGB). Prophylactic cholecystectomy during bariatric surgery may benefit patients with preexisting gallstones, whereas preserving the hepatic branch of the vagus is an important technical consideration, particularly in RYGB, to mitigate postoperative gallstone risk. Pharmacological interventions, such as ursodeoxycholic acid (UDCA), have demonstrated efficacy in preventing gallstones and reducing subsequent cholecystectomy rates. However, consensus is lacking on the optimal dosing, duration, and administration frequency of UDCA across different bariatric procedures. Additionally, dietary measures, such as moderate fat intake or fish oil supplementation, have shown promise in alleviating lithogenic processes. Emerging evidence supports the use of probiotics as a safe and patient-friendly adjunct or alternative to UDCA, given their ability to improve gut dysbiosis and reduce gallstone formation. Further high-quality studies are needed to define standardized prophylactic strategies that balance efficacy with patient adherence, offering personalized gallstone prevention protocols in the era of widespread bariatric surgery.

Understanding the Role of Different ERCP Techniques in Post-Roux-en-Y Gastric Bypass Patients: a Systematic Review and Meta-analysis

We aimed to compare enteroscopy-assisted ERCP (EA-ERCP), laparoscopy-assisted ERCP (LA-ERCP), and endoscopic ultrasound-directed ERCP (EDGE) in terms of safety and efficacy in post-Roux-en-Y gastric bypass patients. We conducted a rigorous analysis based on a predefined protocol (PROSPERO, CRD42022368788). Sixty-seven studies were included. The technical success rates were 77% (CI 69-83%) for EA-ERCP, 93% (CI 91-96%) for LA-ERCP, and 96% (CI 92-98%) for EDGE. Subgroup differences were significant between the EA-ERCP and other groups (p < 0.05). The overall adverse event rates were 13% (CI 8-22%), 19% (CI 14-24%), and 20% (CI 12-31%), respectively (p = 0.49). Our findings suggest that EDGE and LA-ERCP may be more effective and as safe as EA-ERCP.

Ampullary stenosis and choledocholithiasis post Roux-En-Y gastric bypass: challenges of biliary access and intervention

BACKGROUND

Ampullary stenosis following Roux-en-Y gastric bypass (RYGB) is increasingly encountered. We describe cases of biliary obstruction from ampullary stenosis and choledocholithiasis to illustrate the associated diagnostic and interventional challenges with this condition.

METHODS

We reviewed medical records of patients with prior RYGB who underwent a biliary access procedure or surgery for non-malignant disease from January 2012-December 2018.

RESULTS

We identified 15 patients (4 male, 11 female; mean age 53.7 years) who had RYGB on average 11.7 years (range 1-32) years before diagnosis of biliary obstruction. Fourteen patients reported abdominal pain, 5 had nausea/emesis, 12 had elevated liver function tests, and 6 had ascending cholangitis. Mean common bile duct (CBD) diameter at presentation was 16.9 mm (range 4.0-25.0 mm). Operations included 3 transduodenal ampullectomies (2 with biliary bypass), 2 CBD explorations with stone extraction, 1 laparoscopic cholecystectomy alone, 1 Whipple procedure, 1 balloon enteroscopy with sphincterotomy, and 7 transgastric endoscopic retrograde cholangiopancreatography. All ampulla pathology was benign in patients who underwent resection. At follow-up (mean 15.4 months; range 0.23-44.5 months), 12/15 (80%) reported symptom resolution or improvement.

DISCUSSION

Ampullary stenosis after RYGB presents challenges for diagnostic evaluation and intervention, often requiring multi-disciplinary expertise. The underlying pathology remains to be elucidated.