Robot-Assisted Transduodenal Sphincteroplasty for Ampullary Stenosis After Roux-en-Y-Gastric Bypass

Ampullary stenosis can be a late complication of Roux-en-Y gastric bypass (RYGB) causing biliary dyskinesia from ampullary sphincter hypertension (Heetun et al. in Eur J Gastroenterol Hepatol 23:327-333, 2011). Endoscopic management has limited efficacy with Roux anatomy. Thus, pancreatoduodenectomy (PD) may be performed (Wisneski et al. in HPB 22:1496-1503, 2020). In select cases, the morbidity of PD could be avoided using a transduodenal sphincteroplasty.In this report, the case of a patient with ampullary stenosis after RYGB is described. After multiple endoscopic attempts failed to produce durable symptom relief, operative intervention was considered. Choledocho-duodenostomy was deemed technically feasible, but because this patient had preoperative imaging showing that the patient's pancreatic duct communicated independently from the common bile duct (CBD) with the duodenum, robot-assisted transduodenal sphincteroplasty was the selected approach. With this procedure, an extended Kocher maneuver is required for adequate exposure. The lateral duodenal wall is anchored to the falciform ligament using a 2-0 absorbable stitch for retraction. A longitudinal duodenotomy is created along the duodenal wall opposite the major papilla. An 8-Fr catheter inserted through the ampulla into the CBD serves as a probe. Sphincterotomy is performed with electrocautery at the 11 o'clock position, dividing the ampullary sphincter until the CBD wall separates from the duodenal mucosa. A duct-to-mucosa anastomosis is performed using a 5-0 absorbable suture over the 8-Fr catheter, which is left in place: two stitches retracted from the superior CBD facilitate exposure. The duodenotomy is closed transversely with a 3-0 locking absorbable suture in two layers, and a leak test is performed.The patient began oral intake the day after surgery. An upper GI showed no leak on postoperative day 2, and thus the patient was discharged home receiving a liquid diet on postoperative day 3.