Technique for salvage ERCP with gastric bypass anatomy and severe intra-abdominal adhesions.

ABSTRACT

BACKGROUND: Choledocholithiasis is a complex problem in patients with Roux-en-Y gastric bypass anatomy. Several techniques of biliary clearance have been described, but these can be limited by intra-abdominal adhesions. PATIENT AND METHODS: A 36-French surgical gastrostomy was created and was allowed to mature for 10 weeks. It was exchanged for a 15-mm laparoscopic surgery trocar under fluoroscopic guidance. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out using the trocar as a stable access point. Complete biliary clearance was achieved in one sitting using sphincterotomy, large-diameter biliary orifice balloon dilation, and balloon/basket sweeps. RESULTS: Total endoscopy time was 120 minutes. There were no complications associated with the procedure. The postprocedure length of stay was 2 days. The total bilirubin level at discharge was 1.2 mg/dL (20 µmol/L). CONCLUSIONS: In patients with gastric bypass anatomy and severe adhesions, successful salvage therapeutic ERCP can be achieved using a gastrostomy tract and a large-bore laparoscopy trocar for access to the defunctioned stomach.