Video. Laparoscopic transgastric access to the common bile duct after Roux-en-Y gastric bypass

Rapid weight loss after Roux-en-Y gastric bypass (RYGBP) often is associated with gallstones formation, which can lead to cholecystitis and/or choledocholithiasis. Difficult access to the biliary tract is one of the disadvantages after RYGBP. We report a useful technique of laparoscopic transgastric access to the gastric remnant for an endoscopic retrograde cholangiopancreatography (ERCP).

A 40-year-old woman with a BMI of 48 kg/m(2), was submitted to a laparoscopic RYGBP in December 2003. At that time the abdominal ultrasound was negative for gallbladder lithiasis. In April 2007, she was admitted for upper right side abdominal pain, vomiting episodes, fever, and jaundice; the BMI at the time was 24 kg/m(2). Hepatic ultrasound showed lithiasis of the common bile duct with intra- and extrahepatic bile duct dilation, as well as gallbladder lithiasis. The patient was taken to the operating room for laparoscopic evaluation. A pursestring suture was performed on the greater curvature of the gastric remnant. After the opening of the stomach, an 18-mm trocar was inserted into the lumen and the endoscope was directly passed through the port into the duodenum. An ERCP was performed under fluoroscopic guidance, and as a result of sphincterotomy the stone was retrieved. After removing the endoscope, the gastrotomy was closed by tying the pursestring. Cholecystectomy was performed as well.

The procedure lasted 98 min. Liver function tests returned normal on postoperative day 2, and the patient was discharged on postoperative day 4. After 9 months, the patient was well and asymptomatic.

Patients previously submitted to RYGBP and presenting choledocholithiasis can benefit from an ERCP through the gastric remnant.