Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography (ERCP) After Roux-en-Y Gastric Bypass: Technical Features Enrico Facchiano, Giovanni Quartararo, Vittorio Pavoni, Gadiel Liscia, Riccardo Naspetti, Alessandro Sturiale & Marcello Lucchese Obesity Surgery The Journal of Metabolic Surgery and Allied Care ISSN 0960-8923 OBES SURG DOI 10.1007/s11695-014-1516-3
Your article is protected by copyright and all rights are held exclusively by Springer Science +Business Media New York. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”.
Author's personal copy OBES SURG DOI 10.1007/s11695-014-1516-3
HOW I DO IT
Laparoscopy-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography (ERCP) After Roux-en-Y Gastric Bypass: Technical Features Enrico Facchiano & Giovanni Quartararo & Vittorio Pavoni & Gadiel Liscia & Riccardo Naspetti & Alessandro Sturiale & Marcello Lucchese
# Springer Science+Business Media New York 2014
Abstract Background Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The exclusion of stomach and duodenum after this operation makes the access to the biliary tree, in order to perform an endoscopic retrograde cholangiopancreatography (ERCP), very difficult. This procedure could be more often required than in overall population due to the increased incidence of gallstones after bariatric operations. Among the different techniques proposed to overcome this drawback, laparoscopic access to the excluded stomach has been described by many authors with a high rate of success reported. Methods We herein describe our technique to perform laparoscopic transgastric ERCP. A gastrotomy on the excluded stomach is performed to introduce a 15-mm trocar. Two stitches are passed through the abdominal wall and placed at the two sides of the gastrotomy for traction. The intragastric trocar is used to pass a side-viewing endoscope to access the biliary tree. Conclusion In patients with a past history of Roux-en-Y gastric bypass (RYGB), the present technique allows us a standardized, safe, and reproducible access to the major papilla and the biliary tree using a transgastric access. This will
E. Facchiano (*) : G. Quartararo : G. Liscia : A. Sturiale : M. Lucchese Department of Surgery, Bariatric and Metabolic Surgery Unit, Santa Maria Nuova Hospital, P.zza S. Maria Nuova, 50122 Florence, Italy e-mail: [email protected]
V. Pavoni Department of Anesthesiology, Anesthesia for Bariatric Surgery Unit, Santa Maria Nuova Hospital, Florence, Italy R. Naspetti Surgical Endoscopy Unit, Careggi University Hospital, Florence, Italy
lead to simplify the procedure and reduce the risk of peritoneal contamination. Keywords Laparoscopy . Obesity . ERCP . Gastric bypass . Bariatric surgery . Gallstones . Biliary tract
Introduction Gastric bypass is one of the most performed operations worldwide to treat morbid obesity . A possible drawback of this operation is represented by the difficult endoscopic access to the biliary tree . The incidence of gallstones after bariatric surgery is higher compared to the overall population due to the rapid weight loss and altered gallbladder [3–6]. Possible related complications may be managed through an endoscopic access to the common bile duct . Several technical features have been proposed to perform endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic gastric bypass based on an endoscopic or a combined laparoscopic and endoscopic approach. These solutions include a single- or double-balloon endoscopy, a percutaneous gastrostomy on the excluded stomach, or a temporary restoration of the intestinal continuity and laparoscopyassisted transgastric access endoscopy [2, 7–11]. Among the different procedures, transgastric endoscopic retrograde cholangiopancreatography has been described by many authors, reporting a high rate of success with few complications . However, different technical features have been reported. We herein describe our technique to perform a laparoscopyassisted transgastric sphincterotomy by coupling a laparoscopy-assisted transgastric ERCP and the realization of a kind of temporary gastrostomy. This could simplify the procedure and reduce peritoneal contamination.
Author's personal copy OBES SURG
Methods The patient is placed in supine position with legs abducted about 30° and secured to the operating table to allow for subsequent tilting. The surgeon stands between the patient’s legs, the assistant stands on the patient’s left, and two video monitors are placed at the head of the operating bed, on both sides. The first trocar is placed in the left hypocondrium, on the left midclavicular line, using an open access. A 10-mm port site is placed 3 cm above the umbilicus in a media position for a 30° camera, and a 5-mm port is introduced in the upper right quadrant. If needed, above all in the case of a huge liver, an additional port is placed in the epigastric region on the midline for liver retraction. An initial adhesiolysis may be needed to access the area under the liver and to the anterior face of the excluded stomach because of some adhesions that may result from the previous bypass operation. The gastrojejunal anastomosis, the gastric pouch, the jejunal limb, and the excluded stomach are identified. Once the gastric remnant has been identified, a gastrotomy can be realized using a coagulator hook. The ideal area for the gastrotomy is chosen by evaluating the mobility of the stomach and the possibility to pull it towards the abdominal wall. In our experience, the gastrotomy should be performed in the antrum, 6 to 8 cm from the pylorus. After that, two stitches are passed through the abdominal wall and then at the two opposite sides of the gastrotomy. The transparietal stitches should be passed using a straight needle, above all in case of thick abdominal wall (Fig. 1). These two stitches will be subsequently used to hang the stomach and to pull it up to the abdominal wall (Fig. 2). A 15-mm port is inserted through the abdominal wall and it is introduced into the stomach passing through the gastrotomy (Fig. 3). The pneumoperitoneum is decreased to 8 mm Hg, and the stomach is attracted to the abdominal wall by pulling
Fig. 1 After the creation of a gastrotomy, two stitches are passed at two opposite sides using straight needles
Fig. 2 Two stitches are used to pull up the stomach to the abdominal wall
the strings from the exterior of the abdomen. Therefore, the strings can be fixed outside the abdomen using two Kocher forceps, realizing a kind of temporary gastrostomy on the 15-mm trocar. The bed is tilted left and a side-viewing endoscope is introduced into the stomach passing through the 15-mm port. The endoscope is progressed through the pylorus as far as the papilla. Usually, no changes in the patient position on the operating table are needed. To facilitate the progression of the endoscope, the surgeon can guide the progression of the endoscope by moving the trocar at the exterior of the abdominal wall. If needed, the rendez-vous technique can be realized. In this case, the cystic duct is dissected laparoscopically and partially transected. The opening in the cystic duct can be used to insert a flexible guidewire. The guidewire is then moved into the main biliary duct and passed through the papilla. Therefore, the flexible wire is taken by the endoscopist and used as a guide
Fig. 3 A 15-mm trocar is inserted into the stomach through the gastrotomy
Author's personal copy OBES SURG
to enter the papilla. The sphincterotomy is realized, allowing to perform ERCP or to treat biliary strictures or choledocholitiasis. Once the endoscopic procedure is finished, the endoscope is removed from the stomach and the stitches used to secure the stomach to the abdominal wall are cut. The gastrotomy can finally be closed using absorbable interrupted or continuous sutures.
Discussion The access to the biliary tree after RYGB represents a nonnegligible problem. All the techniques described to date present some difficulties, even if they usually achieve good results in a high number of cases . The use of double- or single-balloon endoscopes is an interesting tool that can allow to reach the papilla and the biliary tree for diagnostic or therapeutic procedures . This technique, however, even if it appears safe and feasible, remains a very challenging procedure, needing specific technical means and skilled operators [9, 12]. Many authors have reported endoscopic access to the papilla after RYGB using a transgastric access, obtained by means of a gastrostomy or performing a laparoscopyassisted endoscopic procedure [7–11, 13–16]. A percutaneous gastrostomy, realized using ultrasounds, computed tomography guidance, or an X-rays visible marker left in place during the GBP operation, presents the advantage to allow many attempts to perform ERCP [10, 17]. However, even if a gastrostomy offers a relatively easy access to the biliary tree even using a side-viewing endoscope, it may carry the risk of potentially serious complications [9, 10, 17]. Moreover, as the gastrostomy tube cannot be promptly removed, this technique entails a certain discomfort on daily living activities for several weeks [9, 18]. In addition, unless the endoscopic procedure through the gastrostomy is performed intraoperatively, this approach does not appear feasible in emergency situations because it needs to wait the tract to mature . Laparoscopy-assisted transgastric access appears an interesting option since it allows an easy access to the biliary tract and the possibility to control the whole laparoscopic procedure under direct laparoscopic view. The direct insertion of the trocar into the stomach and the temporary fixation to the abdominal wall is the key point of the described technique. As a matter of fact this technical feature is similar to a temporary gastrostomy, using the intragastric trocar as a gastrostomy tube. This allows an easy passage of the endoscope that can be introduced directly into the stomach and then advanced through the pylorus to reach the papilla. The surgeon, in fact, can guide the progression of the endoscope by moving the trocar as the introduction of a side-viewing endoscope in an unusual anatomy and with the patient in the supine position could result sometimes difficult.
Moreover, the two transparietal stitches at the two sides of the gastrotomy can be used to place adequate traction and countertraction to simplify the introduction of the endoscope. Finally, this technique reduces the peritoneal contamination resulting from the opening of the stomach into the abdominal cavity. As a matter of fact, when the stomach is pulled to the abdominal wall and the trocar is securely inserted into the stomach, the movements and the retraction of the endoscope do not contaminate the peritoneal cavity as it occurs if the endoscope is introduced directly into the stomach [8, 13, 14, 16]. Furthermore, in the described technique, the endoscope is never in contact with the peritoneal cavity during the whole procedure. The direct insertion of a trocar into the stomach to insert an endoscope has already be proposed by Salem et coll et by Bertin et coll [7, 11]. However, in these techniques, the trocar is secured to the stomach using one or two purse-strings, not allowing any sliding of the trocar if needed. By using two stitches kept in tension by forceps at the exterior of the abdomen, the surgeon can vary the position of the trocar in the stomach and the distance of the stomach from the abdominal wall, so facilitating the progression of the endoscope if needed. In conclusion, considering the increase in Roux-en-Y gastric bypass (RYGB) procedures and the correlated expected increase in gallstones formation, it can be assumed that surgeons will be called more and more frequently to face difficult clinical situations needing the access to the major papilla and biliary tree. Among the different options, the transgastric approach appears as a safe and reproducible technique, not needing specific tools or competences except skill in laparoscopic and endoscopic techniques. In patients with a past history of RYGB, the present technique allows us a standardized, safe, and reproducible access to the major papilla and the biliary tree by a transgastric access.
Statement of Informed Consent Informed consent to perform the procedure herein described was obtained from the patient. Statement of Human and Animal Rights—Ethical Approval For this type of study, formal consent is not required. Conflict of Interest The authors declare that there are no conflicts of interest.
References 1. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2008. Obes Surg. 2009;19(12):1605–11. 2. Saget A, Facchiano E, Bosset PO, et al. Temporary restoration of digestive continuity after laparoscopic gastric bypass to allow endoscopic sphincterotomy and retrograde exploration of the biliary tract. Obes Surg. 2010;20(6):791–5.
Author's personal copy OBES SURG 3. Iglezias Brandao de Oliveira C, Adami Chaim E, da Silva BB. Impact of rapid weight reduction on risk of cholelithiasis after bariatric surgery. Obes Surg. 2003;13(4):625–8. 4. Shiffman ML, Sugerman HJ, Kellum JM, et al. Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am J Gastroenterol. 1991;86(8):1000–5. 5. Warschkow R, Tarantino I, Ukegjini K, et al. Concomitant cholecystectomy during laparoscopic Roux-en-Y gastric bypass in obese patients is not justified: a meta-analysis. Obes Surg. 2013;23(3):397–407. 6. Everhart JE. Contributions of obesity and weight loss to gallstone disease. Ann Intern Med. 1993;119(10):1029–35. 7. Bertin PM, Singh K, Arregui ME. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique. Surg Endosc. 2011;25(8):2592–6. 8. Falcao M, Campos JM, Galvao Neto M, et al. Transgastric endoscopic retrograde cholangiopancreatography for the management of biliary tract disease after Roux-en-Y gastric bypass treatment for obesity. Obes Surg. 2012;22(6):872–6. 9. Lopes TL, Baron TH. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. J Hepatobiliary Pancreat Sci. May;18(3):332–8. 10. Martinez J, Guerrero L, Byers P, et al. Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy after Roux-enY gastric bypass. Surg Endosc. 2006;20(10):1548–50.
11. Saleem A, Levy MJ, Petersen BT, et al. Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients. J Gastrointest Surg. 2012;16(1):203–8. 12. Moreels TG, Hubens GJ, Ysebaert DK, et al. Diagnostic and therapeutic double-balloon enteroscopy after small bowel Roux-en-Y reconstructive surgery. Digestion. 2009;80(3):141–7. 13. Nguyen NT, Hinojosa MW, Slone J, et al. Laparoscopic transgastric access to the biliary tree after Roux-en-Y gastric bypass. Obes Surg. 2007;17(3):416–9. 14. Patel JA, Patel NA, Shinde T, et al. Endoscopic retrograde cholangiopancreatography after laparoscopic Roux-en-Y gastric bypass: a case series and review of the literature. Am Surg. 2008;74(8): 689–93. discussion 93–4. 15. Roberts KE, Panait L, Duffy AJ, et al. Laparoscopic-assisted transgastric endoscopy: current indications and future implications. JSLS. 2008;12(1):30–6. 16. Schreiner MA, Chang L, Gluck M, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric postRoux-en-Y gastric bypass patients. Gastrointest Endosc. 2012;75(4):748–56. 17. Ahmed AR, Husain S, Saad N, et al. Accessing the common bile duct after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007;3(6):640–3. 18. Bannerman E, Pendlebury J, Phillips F, et al. A cross-sectional and longitudinal study of health-related quality of life after percutaneous gastrostomy. Eur J Gastroenterol Hepatol. 2000;12(10):1101–9.