Common Bile Duct Stones After Roux-en-Y Gastric Bypass: Same Issue, Different Ways to Deal with

Decrease phase angle one year after Roux-en-Y bypass and sleeve gastrectomy is related to risks to protein nutritional status

BACKGROUND & AIMS

Phase angle (PhA) has been used as an indicator of nutritional status. However, the significance of PhA reduction after bariatric surgery is less known. This study evaluated PhA and its relation with biochemical parameters and prognostic inflammatory and nutritional indices at a one-year follow-up of patients subjected to Roux-en-Y bypass (RYGB) or sleeve gastrectomy (SG).

METHODS

Our final sample consisted of 25 patients subjected to RYGB and 11 to SG. Body mass index, fat-free mass, fat mass, PhA, serum transthyretin (TTR), albumin, C-reactive protein, alpha-1-acid glycoprotein, and prognostic inflammatory and nutritional indices were evaluated at four time points: before and approximately two, six, and 12 months after RYGB or SG. One-way repeated measures ANOVA or the Friedman test with Tukey's post hoc test was used depending on data distribution. The correlation between PhA and biochemical parameters and indices were evaluated using Spearman's or Pearson's correlation coefficients.

RESULTS

Except for serum albumin, all parameters significantly decreased over time (p < 0.001). Only the RYGB group showed transthyretinTR values below reference ones. Prognostic indices significantly decreased in both groups (p < 0.001). We found a significant positive correlation of PhA with TTR in both RYGB (r = 0.475; p < 0.001) and SG (r = 0.457; p < 0.001).

CONCLUSIONS

Data suggest that at a one-year follow-up after bariatric surgery, lower PhA values might indicate a concomitant loss of visceral protein and a worsening of protein nutritional status.

Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass

Background: Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). Furthermore, in these patients, CBDS are difficult to extract due to the altered upper gastrointestinal anatomy following GBP. The aim of the present study was to assess outcome after various management methods applied in the counties of Stockholm and Uppsala, Sweden. Methods: Data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) and the Swedish Obesity Surgery Register (SoReg) were crossmatched to identify all patients who had undergone gallstone surgery after GBP, where CBDS were found at intraoperative cholangiography, in the Stockholm and Uppsala counties 2009-2013. A retrospective review of patient records was performed for all patients identified. Results: In all, 55 patients were identified. These were managed as follows: expectancy (N = 11); transgastric ERCP (N = 2); laparoscopic choledochotomy (N = 3); open choledochotomy (N = 5); transcystic stone extraction (N = 12); and other approach (N = 13). In nine cases, data on management could not be found. There were nine cases of minor postoperative complication. No retained stones were registered. The operation time was longer for transgastric ERCP (p = 0.002), and the postoperative stay was longer following open and laparoscopic choledochotomy (p < 0.001). There was no statistically significant difference between any of the methods regarding the incidence of postoperative complications (p = 0.098). Discussion: Further development of techniques for managing CBDS discovered in patients undergoing cholecystectomy after previous GBP are needed, as well as more comparative studies with greater statistical power.

Image-Guided Surgery for Common Bile Duct Stones After Roux-en-Y Gastric Bypass

Background: The relationship between obesity with common bile duct stone (CBDS) is close and increases after a Roux-en-Y gastric bypass (RYGB). Due to the anatomical modification, direct endoscopic access is not always possible. For this reason, image-guided surgery (IGS) by percutaneous transhepatic biliary drainage (PTBD) of the common bile duct (CBD) could be a first-line approach for the treatment of post-RYGB choledocholithiasis. The aim of this study was to analyze the feasibility and safety of CBDS treatment after RYGB with IGS. Materials and Methods: We present a descriptive retrospective observational multicentric study on the treatment of choledocholithiasis in patients operated on for RYGB using IGS through a minimally invasive approach by PTBD. The diagnosis of CBDS was made according to the symptoms of the patients, supported by blood tests, and medical images. Treatment was planned in two stages: in the first step, a PTBD was performed, and in the second step the choledocholithiasis was removed. Results: Of a total of 1403 post-RYGB patients, 21 presented choledocholithiasis. Of these, n = 18 were included. Symptoms were reported in n = 15 (8 cholestatic jaundice, 7 cholangitis), whereas n = 3 were asymptomatic. Percutaneous treatment was performed in all these patients, treated with a balloon and stone basket. A hyperamylasemia without pancreatitis was observed in 3 patients. No complications or deaths associated with the procedure were reported. The average hospital stay was 8.6 days. Conclusion: IGS is an interesting option for the treatment CBDS after RYGB. For these patients, PTBD is feasible and safe.

Laparoscopic Common Bile Duct Exploration Using a Single-Operator Cholangioscope

Background: Gallbladder stones are a very common disease, with a prevalence of 21.9% in Argentina. The incidence of common bile duct stones (CBDS) varies with age and with the clinical presentation; ∼3%-10% of patients with gallbladder lithiasis have concomitant choledocholithiasis. In the past decades, the development of ultrasound and magnetic resonance cholangiography and endoscopic ultrasound has expanded for the preoperative diagnosis of gallbladder lithiasis. Materials and Methods: We describe the step-by-step technique using the single-operator cholangioscope (pSOC) (SpyGlass™ Discover; Boston Scientific, Natick, MA) under laparoscopic guidance, in a patient with huge stones in the bile duct that was treated with a choledocotomy. Results: The patient underwent the procedure well and the closure of the bile duct was with a primary suture. The current devices, standard cholangioscopes or bronchoscopes, only have a two-way deflection. This problem might be solved with the introduction of a new pSOC device (SpyGlass Discover; Boston Scientific). Conclusion: In conclusion, the combination of laparoscopy and pSOC is a feasible, safe, and effective technique for the treatment of CBDS, and may be considered as an alternative approach in clinical cases where gastrointestinal anatomy is altered or when endoscopic retrograde cholangio-pancreatography (ERCP) failed. pSOC has the potential to reduce peri-procedural adverse events and costs.