Laparoscopy assisted transjejunal endoscopic retrograde cholangiography for treatment of intrahepatic duct stones in a post Roux-en-Y patient

Averting an Unnecessary Revision of a Roux-en-Y Hepaticojejunostomy by Surgically Creating an Access Point for the Endoscopic Assessment of the Anastomosis: A Report of a Case

Introduction: Primary sclerosing cholangitis sets the scene for several pathologies of both the intrahepatic and the extrahepatic biliary tree. Surgical treatment, when needed, is almost unanimously summarized in the creation of a Roux-en-Y hepaticojejunostomy, a procedure with a relatively high associated failure rate. Presentation of case: A 70-year-old male, diagnosed with primary sclerosing cholangitis, was submitted to a Roux-en-Y hepaticojejunostomy due to a dominant stricture of the extrahepatic biliary tree. Recurrent episodes of acute cholangitis dictated a workup in the direction of a possible stenosis at the level of the anastomosis. The imaging studies were inconclusive while both the endoscopic and the transhepatic approach failed to assess the status of the anastomosis. A laparotomy, with the intent to revise a high suspicion for stenosis hepaticojejunostomy, was decided. Intraoperatively, a decision to assess the hepaticojejunostomy prior to the scheduled surgical revision, via endoscopy, was made. In this direction, an enterotomy was made on the short jejunal blind loop in order to gain luminal access and an endoscope was propelled through the enterotomy towards the biliary enteric anastomosis. Results: The inspection of the anastomosis under direct endoscopic vision showed no evidences of stenosis and averted an unnecessary, under these circumstances, revision of the anastomosis. Conclusions: The surgical revision of a Roux-en-Y hepaticojejunostomy is a highly demanding operation with an increased associated morbidity, and it should be reserved as the final resort in the treatment algorithm. An approach of utilizing surgery to facilitate the endoscopic assessment prior to proceeding to the surgical revision of the anastomosis appears justified.

Hepaticojejunostomy Anastomosis Worm Obstruction and Its Laparoscopic Management: A Case Report and Review of Literature

We report a surprising case of intraoperatively detected worm obstruction of a hepaticojejunostomy anastomosis. The patient presented with acute cholangitis including fever, abdominal pain, obstructive jaundice and sepsis. Six years earlier, she had undergone open cholecystectomy with a right subcostal incision. Ultrasonography that night depicted the absence of the gall bladder and the presence of apparent stones in the common hepatic and common bile ducts. The patient was posted for laparoscopic exploration of common bile duct. Intraoperatively, worm obstruction was found in the hepaticojejunostomy anastomosis created during the previous operation. The obstruction was managed laparoscopically, and the patient recovered without any complications and was monitored for two years. In a search of PubMed and Google Scholar, we found reports of laparoscopy-assisted endoscopic retrograde cholangiopancreatography as an established method of relieving hepaticojejunostomy obstruction; however, we found no case of laparoscopic extraction of obstructing worms. Laparoscopic exploration of a hepaticojejunostomy anastomosis through the afferent Roux loop is a feasible and safe alternative to other advanced methods of endoscopic retrograde cholangiopancreatography, for which special technique, logistics, and training are required but may not be available in many parts of the world.

Laparoscopic-assisted transjejunal endoscopic management of intrahepatic calculi and anastomotic stricture in a patient with Roux-en-Y hepaticojejunostomy

Management of complications in patients with Roux-en-Y reconstruction is still today an important surgical and endoscopic challenge. Various techniques have been employed to manage biliary strictures and intrahepatic calculi in patients with Roux-en-Y hepaticojejunostomy (RYHJ). We report the case of a 24-year-old female who had undergone RYHJ reconstruction 3 years back for choledochal cyst, admitted with the diagnosis of obstructive jaundice due to anastomotic stricture and multiple hepatic duct calculi. She was successfully treated with laparoscopic-assisted transjejunal endoscopic management of intrahepatic calculi and anastomotic stricture, which appears to be safe and useful procedure for anastomotic stricture and hepatic duct calculi in patients with surgically altered anatomy.

Transjejunal Laparoscopic-Assisted ERCP: a Technique to Deal with Choledocholithiasis After Roux-En-Y Reconstruction

INTRODUCTION

In Roux-en-Y reconstructions, choledocholithiasis could represent a really challenging condition to treat which can be treated by a surgical-assisted ERCP. Only six cases of transjejunal laparoscopic-assisted ERCP (LAERCP) can be found in literature to date and no large series are present.

METHODS

A young woman who had undergone a laparoscopic Roux-en-Y gastric bypass 2 years earlier came complaining recurrent abdominal pain. Radiologic exams found stones in the common bile duct and no signs of internal hernia. We therefore decided to perform a transjejunal LAERCP finding a concomitant internal hernia in the Petersen's space which was repaired at the same time.

RESULTS

The post-operative course was uneventful.

CONCLUSION

Transjejunal LAERCP is a feasible technique to deal with choledocholithiasis, and it allows at the same time to identify and treat concomitant conditions like internal hernias.

Transjejunal Laparoscopic Assisted ERCP in a Patient with Roux-en-Y Hepaticojejunostomy

Background and Objectives: Nowadays, with the increasing laparoscopic expertise and accessibility to modern surgical tools, laparoscopic assisted ERCP (LAERCP) has become an effective approach for the management of bile stone disease in patients with modified gastrointestinal anatomy. In contrast to patients with gastric bypass in whom a transgastric LAERCP approach is usually performed, the resultant anatomy of Roux-en-Y hepaticojejunostomy precludes a gastric approach as the newly formed bilioenteric anastomosis is not reachable through the stomach. Therefore, a transjejunal approach has been described as an alternative LAERCP technique. To the best of our knowledge this is the tenth case of transjejunal LAERCP reported worldwide. Materials and Methods: We present the case of a 50-year-old female with history of biliary injury during a cholecystectomy corrected with Roux-en-Y hepaticojejunostomy who presented to our center with manifestations of acute abdomen. After laboratory and image analysis, diagnosis of intrahepatic lithiasis was confirmed. The decision to perform a transjejunal LAERCP was made due to the complex anatomy in this patient. No complications were found during surgery and in the follow up period. Conclusions: Transjejunal LAERCP is an effective approach for endoscopic management of biliary complications in patients with Roux-en-Y hepaticojejunostomy and other modified gastrointestinal anatomy. Previous recommendations by more experienced teams have been reported, nonetheless, there are too few cases reported to make definitive recommendations and conclusions. In limited settings, such as ours, some of these recommendations may not be applicable. We are certain that, with the increasing expertise and innovations in laparoscopy surgery for the management of complications that cannot be addressed by endoscopic or noninvasive measures, more cases will be reported.

Transjejunal laparoscopic-assisted ERCP in Roux-en-Y patient: the new right path

The incidence of biliary lithiasis after gastric surgery seems to be higher than in the general population. Endoscopic retrograde cholangiopancreatography (ERCP) allows several biliary and pancreatic pathologies to be dealt with; however, in patients with an altered anatomy of the upper and mid gastrointestinal tract, this endoscopic manoeuvre can be extremely challenging. We report a case of a 79-year-old woman with previous subtotal gastrectomy and Roux-en-Y reconstruction, admitted with a diagnosis of cholecystitis and choledocolithiasis. She was successfully treated with transjejunal laparoscopic-assisted ERCP and laparoscopic cholecystectomy, which appears to be a safe and useful procedure for choledocolithiasis treatment in patients with surgically altered anatomy.

Techniques for endoscopic retrograde cholangiopancreatography in altered gastrointestinal anatomy

PURPOSE OF REVIEW

This review highlights the current status of endoscopic retrograde cholangiopancreatography (ERCP) techniques in patients with altered anatomy. Endoscopic treatment of biliopancreatic disorders is particularly challenging in patients with altered anatomy.

RECENT FINDINGS

There are two main approaches to perform ERCP in patients with altered anatomy: the transluminal access and the transmural access. The transluminal access uses device-assisted enteroscopy (DAE) to reach and cannulate the biliopancreatic system. The transmural access is created using therapeutic endoscopic ultrasound (EUS) or surgery to reach the biliopancreatic system. Both techniques are under continuous development and optimization.

SUMMARY

Based on the currently available data in the literature, the transluminal access is the preferred first-line approach because of an acceptable success rate and an excellent safety profile, whereas the transmural approach may be more efficacious but with a higher complication rate, even in experienced hands. Due to the complexity of both techniques and the relative low number of procedures, patients with altered anatomy are best referred to high-volume centres where both techniques are available for optimal treatment.