Laparoscopic-Assisted Trans-gastric ERCP: An Option for the Management of Choledocholithiasis in the Bariatric Surgery Patient Population Available in the Community Hospital Setting

Introduction: Endoscopic retrograde cholangiography (ERCP) has become a mainstay in the management of choledocholithiasis. Conventional endoscopic access to the Ampulla of Vater becomes impossible after Roux-en-Y gastric bypass (RYGB) due to modified anatomy. In specialized centers with advanced GI capabilities, techniques like double-balloon endoscopy can be utilized for biliary decompression. However, facilitating patient transfer to these centers can be difficult for a common post-operative issue in a large population. Laparoscopic trans-gastric endoscopic retrograde cholangiopancreatography (LTG-ERCP) has been gaining popularity because of its high success rates and ability to carry it out in community healthcare settings. Here we present a case of choledocholithiasis in a Roux-en-Y gastric bypass RYGB patient successfully managed with LTG-ERCP at a community hospital. Case Description/Methods: Our patient is a 51-year-old female with a history of sleeve gastrectomy with conversion to gastric bypass who presents to the emergency department for the evaluation of severe epigastric pain and nausea. Laboratory testing was consistent with elevated bilirubin and alkaline phosphatase levels (1.5mg/dl and 140 U/L respectively). Abdominal ultrasound showed biliary sludge in the common bile duct (CBD). Subsequent Magnetic resonance cholangiopancreatography (MRCP) showed dilatation of CBD measuring up to 1cm with multiple stones in the biliary system (Figure 1). After a multidisciplinary discussion between the GI and surgery teams, a laparoscopic-assisted trans-gastric ERCP along with cholecystectomy was performed and CBD stones were successfully removed resulting in resolution of the patient’s symptoms, and the patient was discharged home without any complications. Discussion: LTG-ERCP is considered a safe and effective approach for managing biliary obstruction after RYGB. This procedure has the advantage of endoscopic biliary decompression and cholecystectomy to be performed in a single setting. In a systematic review, Banerjee et al. reported an overall success rate of 98.5% using ERCP through a trans-gastric approach. This rate is comparable to that of ERCP in patients with normal anatomy. Adverse events were reported in 14% of cases [1]. Choi et al. compared double-balloon ERCP with surgery-assisted ERCP and showed that DB-ERCP had a better safety profile (adverse events rate: 3.1% vs 14.5% respectively; P =0.02) but showed a lower success rate of 80%-90% [2]. References 1. Benerjee et al. Systematic review of transgastric ERCP in Roux-en-Y gastric bypass patients Surgery for Obesity and Related Diseases, Volume 13, Issue 7, 1236 - 1242. 2. Choi et al. ERCP via gastrostomy vs double balloon enteroscopy in patients with prior bariatric Roux-en-Y gastric bypass surgery. Surg Endosc. 2013 Aug;27(8):2894-9. doi: 10.1007/s00464-013-2850-6.Figure 1.: MRCP.